ANNEXURE- “A”

National Power Training Institute (Ministry of Power, Govt. of India)

South Ambazari Road, Gopal Nagar, Nagpur-440 022 (Maharashtra) APPLICATION FORM

POST GRADUATE DIPLOMA COURSE IN TRANSMISSION & DISTRIBUTION SYSTEMS ►Instruction: Use block letters for filling application form

1. Name: __________________________________________ 2. Date of Birth (DD/MM/YY):___________________________

3. Branch of Engineering: _____________________________

4. Whether GEN/SC/ST/OBC/PH:_______________________

5. Sponsored/Non Sponsored :_________________________

6. Email Address: ____________________________________________ 7. Mobile number: ____________________________________________

8. DD Number & Date: _________________________________________

9. Sex: _____________________________________________________

10. Fathers name: ______________________________________________ 11. Postal Address: ______________________________________________

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12. Educational Qualifications (starting from 10th / 12th / Diploma/ Graduation, Stating subjects, College / Institution, % of marks, year of passing,)

Sr No

EXAMINATION PASSED

YEAR

SUBJECTS

BOARD /

UNIVERSITY

PERCENTAGE

OF MARKS/ GRADE

CALCULATED

PERCENTAGE OF MARKS IN

B.E/B.Tech. **

1 S S C

2 HSSC / Dip. In Engg.

3 B.E/ B.Tech.

** Please refer Sr. No. 9, Ann.-B of checklist for documents.

13. Nationality: ________________. 14. Declaration: I hereby declare that the information furnished above is true & correct

to the best of my belief & knowledge. 15. Signature & Date: _____________________________________

Note: Do not attach any document along with the application form, only Demand Draft.

Affix your recent photo here.

ANNEXURE- “B” CHECKLIST FOR DOCUMENTS REQUIRED FOR ADMISSION AT COUNSELLING (Bring one set of attested copies of the documents along with originals for verification)

1. a)Demand Draft of Rs. 75843/-(Rs.67,500/-+S.T@12.36%)

• First installment of training fee for non-sponsored candidates.

• Second installment of training fee to be paid on or before 28/08/2014.

2. b) Demand Draft of Rs.196630/-(Rs.1,75,000/-+S.T@12.36%) Single installment of training fee for sponsored candidates.

3. Hostel charge for 6 months – Rs.12000/- ( If required & allotted) 4. Transportation charges - 1260/- Rs.1200/- + S.T @ 4.94%) 5. Caution money – Rs. 3000/-

• 3( if required)+4+5 in the form of D.D.

• A consolidated D.D. may also be prepared. 6. Matriculation certificate indicating date of birth- 7. HSSC / Diploma in Engineering Certificate-

8. B.E./B.Tech.- Degree/ Final Mark Sheet-

(Indicating Degree Percentage or Marks obtained for award of Degree)

9. In case of CGPA/DGPA/SGPA/CPI/SPI/GPA (Gradation)- Calculated Degree percentage. Furnish a copy of conversion formula

From Registrar or Controller of Examination Of the concerned university to calculate Degree Percentage -

10. Valid caste certificate (For SC/ST/OBC)-

11. For OBC candidates, Non Creamy Layer certificate Issued after 01/04/2014 in Central Govt. format -

12. For Physically Handicap candidates- Valid PH certificate- 13. For Sponsored candidate-

a. Copy of appointment letter.

b. Sponsorship letter / Certificate from employer c. Experience certificate. d. Copy of last 12 salary slips.

e. Copy of Bank statement of credit of salary for last 1 year Attested by bank manager. f. Undertaking/ Declaration as per Annex. “C”.-- 14. Signature: _______________________.Date :__/___/___. Note: All claims regarding Age/Degree Percentage/Caste/PH must be supported by

valid documentary proof.

• Incomplete application/application not in the given format will not be accepted.

• Change of Data / Information shall not be allowed later on, in any case.

• Application fee is non-refundable & non-transferable.

• Applications after due date will not be accepted.

ANNEXURE- “C”

Format for Submission of Undertaking/ Declaration (On Rs. 10/- Non Judicial Stamp Paper) to be submitted by sponsored candidate seeking

admission in Post Graduate Diploma Course in Transmission & Distribution Systems at NPTI (WR), Nagpur.

I…........................................................................ (Name of the candidate) s/o_____________________________ (father’s name), Resident of________________ (full permanent address) working at ___________________ (name of the company) as____________________(designation) having been sponsored by the aforesaid company for pursuing Post Graduate Diploma Course in Transmission & Distribution Systems at NPTI, Nagpur hereby solemnly affirm, undertake and declare that :

1. The Deponent is well aware and recognizes the benefit and sponsorship being accorded to him by his Employer Company mentioned above to pursue the course “POST Graduate Diploma Course in Transmission & Distribution Systems” at NPTI (WR), Nagpur.

2. That Deponent in recognition of above unconditionally undertakes that under no circumstances he/ she shall volunteer or claim for campus recruitments conducted at the Institute.

3. The deponent shall be bound by the present undertaking without fail and the same is being tendered without any pressure or coercion from the Employer or NPTI Institute.

Deponent

(Candidate’s name & address) In the presence of-

1. Witness (Full Name & Address)

2. Witness (Full Name & Address)