INDIAN INSTITUTE OF COMPUTER STUDIES Managed by Gayatri Educational Trust Tulasichoura, Baripada, Mayurbhanj Examination From Name of the Examination* Name of the Center* IICS, TulasichouraIICS, KhuntaIICS, DeulasahiIICS, BalasoreIICS, TakatpurIICS, MadhubanIICS, JharpokhariaIICS, Debendrapur Registration Number* Date of Form Fillup* Name of the Course* —Please choose an option—ADCA/Adv.PGDCAPGDCAADCHDCA‘O’ LEVELSpoken EnglishCADCAACCACOCTALLY ERP9Other Course Name of the Student (in block letter)* Date of Birth* Name of Father (in block letter)* Name of Mother (in block letter)* Name of the Guardian if any (in block letter):* Address Mobile No Annual In-come of Parents (Rs) Caste S.TS.CO.B.CGEN Religion Nationality* Education Qualification Fees paid up to Month & Year* No. of Days / Class attended Whether pupil phsically disabled* NoYes Whether visually physically disabled* NoYes Declaration: I hereby declare that I have read and understood the instructions given above I also affirm that I have submitted all the instruction filled in the examination form and my registration for the course is valid and not time barred. If any of my statements is found to be untrue, I will have no claim for taking examination. I undertake that I shall abide by the rules and regulations of the institution. Date Signature of the Student (Upload in jpg, jpeg, png format within 500kb) Note: You will be intimated by management after submission.