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2B, 4th Floor, Gokul Towers, No.7, C.P.Ramasamy Road, Alwarpet, Chennai - 600 018. Tele: +91 44 4353 5335, +91 44 4211 3004 www.nistinstitute.com, [email protected] F/MK/01/NEBIGC

NEBOSH International General Certificate (U.K.)APPLICATION FORM

Please submit a copy of any photo id Please Tick (√)

OthersDriving LicensePassport Copy Please Specify:

Please fill in the required details for the registration of NEBOSH International General Certificate (U.K) along with 2 passport size photographs for our perusal. Please type or Print clearly:

PERSONAL INFORMATIONTitle

(Please Tick (√) in the appropriate column)Mr Mrs Miss Dr Others

First Name

Last Name

House Number Street Name & Address

City Country Postal Code Country of Residence

Date of Birth: (DD / MM / YY) Gender: Please Tick (√) Nationality

Passport Number

Landline Mobile Phone Official Number

E-mail

PROFESSIONAL INFORMATION

PRESENT EMPLOYMENT

DESIGNATION

TOTAL YEARS OF EXPERIENCE

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Male Female

mailto:[email protected]

http://www.nistinstitute.com/



OTHER HEALTH & SAFETY QUALIFICATIONS

ACADEMIC QUALIFICATION

MONTH OF JOINING

HOW DO YOU KNOW ABOUT US

SELF SPONSORED (Yes/No)

SPONSORING COMPANY (Name of Company / Invoice to be addressed to Department)

EXAMINATION DETAILS – (External candidates only)

Please indicate the unit examination/s for which you are registering. [Please Tick (√)]

IGC1 – Management of International Health and Safety

IGC 2 – Control of International workplace hazards

IGC 3 – International health and safety practical application

Please provide your PIN/student number for any previously taken NEBOSH qualification/s

If you are retaking a unit, please give us the following information

Course Provider

Student Number

Date/s of previous sittings

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Payment Mode: (Please tick the appropriate box)

Payment details:

1. Cheque/DD shall be provided in the name of NIST Institute Private Limited.2. Online transfer could be done to any of the bank accounts given below.

Cheque CashOnline Transfer DD



HDFC BankName of account – NIST Institute Private Limited

281, Mount RoadTeynampet, Chennai - 600 018

A/c. No: 15862320000051IFSC Code: HDFC0001586

Swift Code: HDFCINBB

HDFC Bank, BangaloreName of account – NIST Institute Private Limited

26, Ground floor, Akshaya ComplexVictoria Layout, Bangalore 560 047.

A/c. No. 17512020000054 IFSC Code: HDFC0001751

Swift Code: HDFCINBBBNG

Bank Details

TERMS AND CONDITIONS:

Prior registration is required as there are only limited seats.

Registration forms, copy of passport, passport size photos should be submitted on or before the last date of every batch.

Cancellation should be confirmed in mail as scanned copy duly signed by the candidate or as a hard copy.

Cancellation made after the concluding date of registration will not be refunded at any cost.

Cancellation made 1 week prior to the concluding date shall returned 50% of the total fee.

Cancellation earlier to 2 weeks of the concluding date will be charged as administration cost of 12% of the total fee.

NIST Institute Private Limited will cancel the training due to unavoidable situation. However, we will bring the rescheduled course to delegates’ notice in much advance and if necessary we have rights to change the tutor for any critical situation.

I declare that the information herein is true and correct to the best of my knowledge, I accept the Terms and Conditions within the application document and I understand that this application is subject to approval by NIST.

Signature ______________________________________________ Date ____________

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OFFICE USE ONLY Applicant No# __________ Reviewed by ______________ Date _______________ ACCEPT Month of joining: ________________ REJECT

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