[Run by Sri Sambu Mahaa Rishi Educational Trust (Regd.No. 718/2002)
Approved by Tamilnadu Board of Continuing Education
State Resource Centre for Adult & Continuing Education,
An Autonomus Institution Governed by Governing Body Constituted by Ministry of Human Resource Development GOVERNMENT OF INDIA
APPLICATION FOR ADMISSION
Admn. No.         Reg. No.
Personal data          Date :
Name : Photograph
Communication Address :
 Permanent Address :
Date of Birth
  DD/MM/YY 		Place of Birth :
Sex : Male Female Marital Status : Single Married

If we had to contact you by telephone, what is the best, at what numbers ? (with Code numbers).
Business Residence
Fax         E-mail       

Course Applied for :
(Please tick mark in the specified box which the course yor are apply)

Fire & Safety Management
Electrical Safety Management
Industrial Safety Management
Industrial Hygiene Management
QA & TQM
Quantity Surveying & Evaluation
Project Management

Educational Qualifications
Course Course Title Board of Education Location of Board Major Year of
Passing		 Grade/
Percentage
10 Years/ equivalent
10 + 2 equivalent
UG / Others

DECLARATION BY THE APPLICANT

I hereby declare that I have read the prospectus thoroughly and understood the conditions of eligibility for the programme for which I seek admission. I fulfill the minimum eligibility criterial & I have provided necessary information in this regard. In the event of any information being found incorrect or misleading, my candidature shall be liable to cancellation by the institution at any time and I shall not be entitled to refund of any fee paid by me.

Place :

Date  :

Student's Signature


Tick mark the enclosure under the Course you select
 (Applications without Photocopies with attestation as mentioned below will be rejected)

Two Passport Size and One Stamp Size Photograph
Photo Copy of the SSLC Mark Statement with Attestation
Photo Copy of the HSC Mark Statement with Attestation
Photo Copy of the Transfer Certificate with Attestation

FEES DETAILS
Mode of Payment Cash Demand Draft Cheque
Fee Paid Receipt No. Date Balance