A-1 Application form

for CST-2011 Examination

(for appearing in the CST-2011 exam)

For Office Use Only:

Degree/Diploma Qualification: Completed/
Staple 2 photos (strike out as appropriate) Not Completed Paste 1
here with your Fees Paid: Passport-size
name written CST ID: Photograph
on the reverse. here.
Do not paste. Do not staple.
(recent photo taken after (recent photo taken after
1/08/2010) 1/08/2010)
FORM TO BE FILLED IN CAPITAL LETTERS ONLY (refer guidelines for form A-1 in Section 4)
(Provide one space after each word)
1. Name of Applicant:

2. Password min 5 and max 10 characters

3. Address for communication:

City:
State: Pin Code
4. E-Mail:
5. Mobile:
6. Office Phone with STD-Code:
7. Residential Phone with STD-Code:
8. Date of Birth 9. Gender: M F
D D M M Y Y Y Y
10 Category: General SC ST OBC
11 Level of exam (Tick One) appearing for E I D G
12 Examination City Information
City Code City Name

13. If interested in employment, please tick your choice(s)

In C-DAC Centres: Mumbai Bengaluru
Other Selected C-DAC centres

14. Applying for dissertation project at C-DAC, Mumbai and Electronics City, Bengaluru
For D/G Level Candidates only (MCA/ME/M.Sc/M.Tech. Projects)
15. If interested in admission to courses offered by other institutes as follows, please tick your choice(s)
Goa University : MCA BCIDS NMIMS: MCA ISME: PGPM
Smt. Parvatibai Chowgule College of Arts & Science Goa : M. Sc. (IT)
CST-2011
65
16. If you have taken CST – 2010 examination, provide the details
Year: CST ID
17. If completed / doing FGPDST/ PGDST/ PGDIS/APGDST /PGDIT/ ,
Mention your Student ID

18. Completed Degree/Diploma (excluding C-DAC courses)

Discipline:
Year of Passing Marks (%/GPA) Division
19. Appearing Degree/Diploma (excluding C-DAC courses)

Discipline:
Current Sem. Likely month &year of completion
20. University Name

21. Fee Details

Level Total Examination fees Your Choice
Physical Online (Tick one)
Application Application
E 650 600 �
I 750 700 �
D 850 800 �
G 950 900 �
22. Payment Details: Cash DD
DD should be drawn in the favour of: “C-DAC, Mumbai” payable at Mumbai
DD Date: DD Number:
D D M M Y Y Y Y
Bank Code (9 digit number on the DD):
Bank Name:

Bank Branch:
Bank City:

23. Declaration: I declare that all the information provided by me in the A-1 application form is
true and correct to the best of my knowledge and belief.
I understand that my FPGDST/FPGDIS course admission will be cancelled/C-DAC recruitment
will be terminated, if any of the information given by me in this form is found to be false OR if I
fail to submit the required documents on or before December 31, 2011.

Signature:

Place: Date: