Nomination cum Registration Form

(Form must be filled in capital letters only)

('*' = Mandatory )

Name of The Training Programme * :

Date of The Training Pro.:

From:

To:

Name of The Officer:

Surname * :

Name * :

Father's / Husband's Name * :

Male / Female:

Designation * :

Class I or II * :

Educational Qualification * :

Name of the Office.
(Please write full Name ) * :

Office Address:

Residential Address:

Telephone No. With STD Code:

Office:

Residence:

Mobile:

Fax:

E-mail Address:

Date of Birth:

Service Information:

Class I From:

To:

Class II From:

To:

Training Prog. in which you have participated (Previous Training Records if any):

From:

To:

From:

To:

From:

To:

Hostel Accommodation Required :

Course Fees 200/- Per day per trainee as per G.R.No. (વતભ-૧૮૦૪-૫૫૦૦/વસુતાપ્ર.-૩, સચિવાલય, ગાંધીનગર તા. ૧૧-૦૮-૨૦૦૮)

Draft No		Date:		Amount:
Cheque No		Date:		Amount:

Course Fees are to be paid by Draft / Cheque in favour of ' Deputy Director Accounts, SPIPA, Ahmedabad.

Note:Outstation Cheque will not be accepted.