www.iactglobal.

in
Application Form for Certification Programmes of CEP, IIT Delhi
(Email the filled application form to registration@iactglobal.in ONLY. Forms sent to any
other email id will not be accepted)
(Fields marked with * are mandatory & Form should be filled in block letters. Only black/blue ink)
Course Name*: _________________________________________________________
PERSONAL DETAILS of CANDIDATE
Full Name* _______________________________________________________
(please write full name required to be printed on the Certificate)

Fathers Name*: ___________________________________________________

Date Of Birth (dd/mm/yy)*: ______________________ Gender*: _____________
E-mail Id* ________________________________________________________
Educational qualification (attach Photocopy of Degree/Final Year Marksheet)*:Graduation degree

University

Year of Passing

% of Marks

Additional Qualification (if any):

Postal Address*:
____________________________________________________________________
______________________________________________ Pin/Zip Code: ________________________
Phone (Home): _______________________________ Mobile: ______________________________
PROFESSIONAL DETAILS
Name of the Company: _____________________________________________________________
Present Designation:
______________________________________________________________________
Total Work Experience: _____________________________________________________________
Address (Work): ___________________________________________________________________
Phone (Work): ____________________________________________________________________
[OPTIONAL]
How would this programme help you in your work profile and professional
development?
___________________________________________________________________________________________
___________
___________________________________________________________________________________________
___________

__________________________________________________________________________________
__________

Name/ Signature of Candidate

Date

www.iactglobal.in
I hereby declare that the information provided herein is correct to the best of my knowledge and belief.
Moreover, I agree to the terms and conditions of IACT Global (mentioned on www.iactglobal.in). I shall
complete the programme within the duration of 3 months.

Name/ Signature of Candidate

Date