C++ PROGRAMMING & DATA STRUCTURE

Duration : 26th to 31st December, 2016

Attach recent color

1. Name (In Block Letters) : .

passport size photo
3.5 cm X 3.5 cm

2. Institution / Company : .
(Attach Identity Proof)
3. Designation :

4. Postal Address : ..
.....
STATE : . PIN : ..
5. Phone (Mob.) : .......... Phone (Resi.) : ................
E-mail (Compulsory) : ..
6. Gender (Male / Female) :
7. Date of Birth : .
8. Highest Academic Qualification : .
Percentage / CGPA :
(Attach mark sheet / grade sheet showing performance in C programming course)
9. Accommodation Required (Yes / No) :
10. Demand Draft of Rs.: ___________ , No.: ________________ , Dated:
drawn on

/____/ 2016,

(Bank) in favour of

CEP-STC, IIT Kharagpur payable at Kharagpur.

11. Sponsored by (not applicable for self-sponsored candidate):

Signature and Seal of the

Date:
Head of the Organization
______________________________________________________________________________
Date :
Place :
___________________________________
Signature of the Applicant.