Application

INSTITUTE OF CHEMINFORMATICS STUDIES
C-56A/28, 1^st Floor, Sector-62, Noida-201301, (U.P) INDIA
Tel:- 0120-4320801/02, Mob:- 09873719423
Website: www.icis.co.in, e-mail: info@icis.co.in

Application Form
Distance Learning Programs

Program Applied For:
1. Industry Program in Paint & Coating Technology
2. Industry Program in Cheminformatics
3. Industry Program in Petrochemical & Refining

Participation No.________________________
(For office use only)

All columns are compulsory, No columns should be left blank, All in block letters.

1. Candidate's Name*

2. Father's / Husband's Name*

3. Date of Birth*

4. Sex

Male Female

5. Address for Correspondence*

City____________________State_____________________PIN______________

Country__________________________Nationality________________________

6. Telephone No.(If any)*

Code_________(O)____________(R)_______________(M)_________________

7. E-Mail*

8. Last Academic Qualification*

Exam Passed	Board / University	Year	Result (with %)

9. Work Experience (if any)

Full Name of Organization	Designation	Total Work Exp.(if any)

Payment Details:

10. Demand Draft No._____________Dated_______________Drawn on_________________for Rs.______________
(Bank Draft must be drawn in favour of "Institute of Cheminformatics Studies" payable at Noida/Delhi. Candidates are advised to write their name and address at the back of demand draft.)

11.Documents to be attached with application form:

i) Fee DD/Cheque ii) Photocopies of Last Academic Qualification with self attested. iii) 2 Copies of passpost size photograph one pasted and one pinned.
Note: At par cheque only accepted.

*Mandatory to Fill

**Declaration by the Participant

I hereby declare that I have read and understood the conditions of eligibility and objectives of the program for which I seek participation and am eligible for the same. I uderstand that this is ICIS's independent knowledge enhancement training program which is professional in nature and the enrollment in / completion of the program does not promise any employment or any specific eligibility to pursue higher studies. Disputes if any are subject to jurisdiction of Noida, District Gautam Buddha Nagar Courts only. I also understand that the fee is non refundable and nor shall the fee will be transferred or adjusted in any other program or service.

Date:

Place:

(SIGNATURE OF THE PARTICIPANT)

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