JPR Center Cod | Fea no € RKCL, Name ottt-6 Application Form for Admission to Rajasthan State Certificate in Information Technology (RS-CIT) Please fil in the form using BLACK ink and with in BLOCK letters Name of the applicant as it should appear on the RS-CIT Certificate / as it appears on SSC Certificate Date of Birth HH Age :[ Dai Worth Years Gender : Male[_] / Female["] Mother Tongue: Marital Status: Married / Single Qualification ‘Address for Correspondence [Address City / Town / Village Tahsil District State Pin Permanent Address (Please enter only i itis not same as above ) [Address City Town / Vilage Tahsil District State Pin Telephone No. (Residence) (Office) Area code Telepone Number ‘rea ode Telepone Number E-mail ID : Category : College Student |_]/ Schoo! Student [_] / Post Graduate Student [_] / Govt. Employee [_] / Professional |] / Business Person [_] / Housewife [_] / Senior Citizen [_] / Others (specify) ‘Are you Physically Challenged? Yes/No. (if yes, please attach certificate giving detalls of desabiliy) Your choice of RS-CIT course Batch , Medium and Mode (please read the important instruction to RS-CIT student before filing in these details) Medium of instruction English] Hindi] RS-CIT Batch | Commencement Deis Won Yeas Mode of study (Please refer to table overleaf): Regular | Reaular wit [| Regular wit) Please se attached herewith the true copy of my PAN Card / Voter's Card / Driving License / Passport / Government ID Card / Collage or ‘School ID Card as proof of my identity. hereby solemnly affirm that my name, photograph and signature on this application form match with the copy of the proof of my identity attached herewith by me, | undertake to carry this proof in person al the time appearing for RS-CIT ‘examination (Applicant should countersign the copy of the proof of identity attached herewith by him / her) For Centers Use Only Center Code pamper tn Name ofthe Carer ioc Receipt No Forres. ne apolar carl eMC, Toby SO al nae PROT aN SATS pollo ons apgleton tem mah wh Powe ono orga a rose grin Bk ony testy poder vector ard tote cipy sachs heron ye te above bn pte nave Saute! Be sane sominectatiaten 4, Ce 3 sve poten ope Date. ‘on permission letter and RS-CIT Certificate [of center Coordinator structions and information ptr English and Hind on the backside this frm land wil abide by them, have rcaived the counterpart of tis same informatio for my records. Feo at eft oi tir er eg ane rere fe eee eT Fase emer sofa ere a ‘Signature of Applicant