Application Form for registration of Maharashtra State Certificate in by irues2342

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                                                                                                         Form No.:




                                           Application Form for registration of
        Maharashtra State Certificate in Information Technology (MS-CIT) Authorized Learning Center
   1.    Master Franchisee (MF) Information
             a. MF Code : _____________________
             b. Name of the MF : ____________________________________________________________________________
             c.   MF Location & State: ____________________________________________________________
   2.    Applicant Organization’s (AO) Information AO should attach to this application photographs(4” X 6”) of the interior &
         exterior view of the proposed premises, computer lab, classrooms, etc. and the certificates applicable) Exhibit – 2
             a.   Name of AO : ______________________________________________________________________________
             b.   Proposed AO ALC Name :______________________________________________________________________
                  ___________________ (Note: This name will appear in all documents of MKCL in future as its ALC, if approved)
             c.   Address : __________________________________________________________________________________
                  __________________________________________________________________________________________
             d.   Ward No. : __________________________ Ward Name: ____________________________________________
                  Suburb: ____________________________ Nearest Landmark _______________________________________

             e.   City : ________________________________ Pin 

             f.   Tehsil : ___________________________ District : ____________________ State: ________________________
             g.   Telephone Office: STD Code ________ No. _____________ Email Address______________________________
             h.   Name and address of Nearest Post
                  Office:_________________________________________________________
             i.   Name of Municipal corporation/council: _________________________________________________________
             j.   Type of Organization : (Tick  )

                  Private Limited Company              Public Limited Company             Trust            Society    
                  Cooperative Society                  Partnership                        Proprietorship Other ______

             k.   Registration No. ___________________________ Registration Date : ____________________ (DD/MM/YYYY)
             l.   Registered under which act : (Tick  )

                  Companies Act, 1956                  Charitable & Religious Trusts Act           Indian Trusts Act   
                  Societies Registration Act           Cooperative Societies Act                   Others              _____
             m. Governing Document : (Tick  )

                  Memorandum of Association            Articles of Association            Trust Deed   
                  Rules and Regulations             Partnership Deed                      Others        ____________



AO ALC Coordinator’s Signature                       MF Coordinator’s Signature                      SLC Coordinator’s Signature
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            n.   Certificates : (Tick  )

                 Certificate of Incorporation       Registration Certificate   
                 Shops & Establishment Act          Other                       _________________________
            o.   Designation of the Competent Authority/Head/Owner of the AO : (Tick  )

                 Chairman          Managing Director        Managing Trustee         Sole Proprietor    
                 Director          Partner                  Principal                Registrar         Other    ______
            p.   Brief Description of activities conducted by AO ____________________________________________________
                 __________________________________________________________________________________________
                 __________________________________________________________________________________________
   3.   Details of Competent Authority/Head/Owner of the AO

                            Full Name: _________________________________________________________________________
                                              (First Name)  (Middle Name – Father’s/Husband’s)     (Last Name)
                            Gender :( Tick  ) Male/Female Date of Birth: ____________ (DD/MM/YYYY) PAN No.:_________

                            Qualifications (in chronological order):___________________________________________________
        Photograph
                            Address for correspondence: ___________________________________________________________

                            City: __________________________ Pin 

                            Tehsil________________________District______________________State______________________

                            Telephone Office: STD ________Tel No. _______________ Resi. STD _____Tel No. _______________

                            Mobile No.____________ Email (1) _______________________ Email (2) _______________________

   4.   Bank Account Details of the AO: (If you have HDFC account, please attach HDFC Account Opening letter) : Exhibit – 4

        Account No:                                                Type of Account: Savings/Current
        Account Name:
        _____________________________________________________________________________________
        Name of the Bank: _________________________________ Bank Branch, City: _________________________________
        Tehsil: __________________ District: ____________________ State: ____________________Pin:           
   5.   Payment Details : (The DDs should be drawn in favour of MKCL, payable at Pune Location on a nationalized bank only) :
        Exhibit – 5
        Details of Demand Draft 1

                 DD Amount: Rs. 3000/-        DD No. : __________________________ MICR Code: ________________________

                 Drawee Bank: __________________________________ Branch: ______________DD Date: _______________

                 (This demand draft shall be returned to the AO, if application is rejected by MKCL SLC)

        Details of Demand Draft 2

                 DD Amount: Rs. 500/-         DD No. : __________________________ MICR Code: ________________________

                 Drawee Bank: __________________________________ Branch: ______________DD Date: _______________




AO ALC Coordinator’s Signature                    MF Coordinator’s Signature                        SLC Coordinator’s Signature
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   6.   Infrastructure Resources of the proposed ALC : Exhibit – 6
            a.   Premises & General Infrastructure Resources (Please attach supporting documents)

                                                          To be filled by AO       MF Remarks
                 Premises (Owned/Rented/Leased)
                 Total Area                                               sq.ft.
                 Counselling & Administration Area                        sq.ft.
                 Lecture Room                                             sq.ft.
                 Lecture Room                                       No of Seats
                 Laboratory Room                                          sq.ft.
                 Laboratory Room                                    No of Seats
                 Staff Room                                               sq.ft.
                 Staff Room                                         No of Seats
                 Library No of Books on IT & allied
                 subjects
                 Other Infrastructure
                 Display Facility in lecture room         OHP/LCD
                                                          Projector/Writing
                                                          Board
                 Clean & Hygienic Drinking water
                 facility
                 Toilets (Ladies & Gents Separate)
                 Pantry
                 Power Conditioning
                 No of 5Amp outlets for computers
                 UPS capacity                             KVA :
                                                          Backup time in mins:
                 Diesel Generating Set                    KVA :
                 Air Conditioning                                   Tonnes
                 Fans
                 Fire Safety
                 Parking Capacity for two wheelers
                 Please Note that Xeroxing or telephone booth activities should not be carried out in the area of ALC




AO ALC Coordinator’s Signature                      MF Coordinator’s Signature                  SLC Coordinator’s Signature
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           b.   Computing Facilities installed at the proposed ALC
                        i. Hardware
                No CPU Type CPU         RAM     CDROM HDD         Monitor Keyboard Head- Server MF’s Remark
                                Speed           Type     Capacity Size,     / Mouse phone /
                                                                  Type                    Client
                1
                2
                3
                4
                5
                6
                7
                8
                9
                10
                            (For additional information, please attach separate sheet)
                        ii. Local Area Networking, Internet, Peripherals

                                                       To be filled by AO           MF Remarks
                Ethernet 10/100 Base T Switch
                CAT 5 structure Cabling with RJ
                45
                Patch Cables
                Modem
                (Dialup/Broadband/ISDN/Leased
                Line)
                Availability of an internet
                Connection
                Type of Internet Connection &
                Bandwidth
                Name of ISP


                PERIPHERALS (Please write the
                specifications)
                Scanner
                Printer
                CD Writer
                Web Cam
                Backup devices
                Others



AO ALC Coordinator’s Signature                    MF Coordinator’s Signature                       SLC Coordinator’s Signature
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                Licensed Software availability
                Operating System (Server)
                Operating System (Client)
                Office Automation tools
                Antivirus software suite
                DTP Software
                Others


           c.   Human Resource appointed at the ALC (Please attach the bio-data) Exhibit 6c
                    i. Center Coordinator

                                  Name: ______________________________________________________________________

                Photograph        Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick  ) Male/Female

                                  Qualifications: ____________________________________ Experience______ (No of
                                  months)

                                  Mobile No _______________________________ Email Address _______________________

                    ii. Faculty

                                  Name: ______________________________________________________________________

                Photograph        Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick  ) Male/Female

                                  Qualifications: ____________________________________ Experience______ (No of
                                  months)

                                  Mobile No _______________________________ Email Address _______________________

                    iii. System Administrator

                                  Name: ______________________________________________________________________

                Photograph        Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick  ) Male/Female

                                  Qualifications: ____________________________________ Experience______ (No of
                                  months)

                                  Mobile No _______________________________ Email Address _______________________

                    iv. Counsellor

                                  Name: ______________________________________________________________________

                Photograph        Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick  ) Male/Female

                                  Qualifications: ____________________________________ Experience______ (No of
                                  months)

                                  Mobile No _______________________________ Email Address _______________________




AO ALC Coordinator’s Signature                   MF Coordinator’s Signature                   SLC Coordinator’s Signature
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   7.   Declaration by AO ALC
        I/we wish to apply to register our center as the ALC for conducting MKCL’s MS-CIT course at our above mentioned
        premises.
        I/we have been provided with adequate training and orientation by Master Franchisee __________________________
        _______________________ on the methodology of conducting MS-CIT course. I/we further undertake to implement
        the course in accordance with and complete adherence to MKCL norms as decided from time to time and as published
        on MKCL’s website.
        I/we further undertake that I/we shall be responsible for all costs, consequences, expenses, liabilities, obligations, and
        damages brought against or suffered by MKCL resulting from or arising out of or relating to any discrepancies, acts,
        omissions, negligence, misrepresentation, and malpractice whether directly or indirectly, committed by me/us,
        subsequent to registration as the ALC.
        Name of competent authority: _____________________________________________________
        Designation ___________________________
        Date _______________________
        Place ___________________
                                                              Seal & Signature of Competent Authority/Head/Owner of AO ALC


   8.   Recommendation and declaration by the Master Franchisee
            a.   We have scrutinized this application form carefully. Both the demand drafts are correct and are payable at
                 respective city.
            b.   We have sought the necessary clarification from the AO ALC
            c.   Our Authorised representative Mr. /Ms. ________________________________________ _____ has visited
                 the proposed ALC and inspected the infrastructure and computing facilities at the applicant organization’s
                 premises mentioned herein, and it is found to be in working condition.
            d.   Our Authorized representative Mr. /Ms. ________________________________________ has interviewed the
                 Center coordinator, Faculty, System Administrator, Counsellor at the applicant organization’s premises
                 mentioned here in.
            e.   Based on our visit, inspection, interview and verification, it is found that the information furnished by the AO
                 ALC in this application form and attached documents are/not correct and found to be in/not in adherence to
                 MCKL norms. The infrastructure, computing facilities and human resources at the AO is/are not in accordance
                 with MKCL norms.
            f.   We, therefore, recommend that this center may/may not be given MKCL’s Registration as ALC for conducting
                 MS-CIT course with effect from _____________(DD/MM/YYYY)
            g.   We recommend that this center shall work under our DC ________________________ _____________, if this
                 center is recommended in item F above.
            h.   We further, undertake to indemnify and hold MKCL harmless from and against all claims, losses, liabilities,
                 obligations, damages and expenses brought against or suffered by MKCL resulting from, arising out of or
                 relating to any discrepancies, acts, omissions, negligence, misrepresentation, malpractice, whether directly or
                 indirectly, committed by us in the process of scrutiny, recommendation and approval of this application.




AO ALC Coordinator’s Signature                   MF Coordinator’s Signature                       SLC Coordinator’s Signature
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            i.   We have entered all the details of the center on MKCL’s website from this application form in error-free
                 manner. We shall hand over the DD1 and DD2 to our SLC ____________ ________________ only with this
                 application form and attached documents.
            j.   Notes :
            k.   Reason (Please specify in case of rejection)
                 Name of Master Franchisee _________________________________________________
                 Name of Authorised Signatory _______________________________ Designation _______________________
                 Date _______________________
                 Place _______________________
                                                                               Seal and Signature of Authorized signatory of MF


   9.   Recommendations and Declaration by State Lead Center (SLC)
            a.   I have scrutinized this application form carefully.
            b.   I have sought the necessary clarifications from the MF about the items in application form.
            c.   We, therefore, recommend that this center may/ may not be given MKCL’s registration as ALC for conducting
                 MS-CIT course with effect from __________________(DD/MM/YYYY)
            d.   We further, undertake to indemnify and hold MKCL harmless from and against all claims, losses, liabilities,
                 obligations, damages and expenses brought against or suffered by MKCL resulting from, arising out of or
                 relating to any discrepancies, acts, omissions, negligence, misrepresentation, malpractice, whether directly or
                 indirectly, committed by us in the process of scrutiny, recommendation and approval of this application in case
                 of AO recommended as ALC.
            e.   Notes :
            f.   Reason (Please specify in case of rejection)
                 Name of State Lead Center _________________________________________________________________
                 Name of Authorised Signatory _________________________________________ Designation____________
                 Date ___________________
                 Place ___________________
                                                                              Seal and Signature of Authorized signatory of SLC
   10. Acknowledgement by the AO recommended as ALC
            a.   We have received the welcome kit
            b.   All electronic correspondence should be mailed on our email ID ________
                                                                       Seal and Signature of Authorized signatory of ALC
   11. Acknowledgement by the AO NOT recommended as ALC
            a.   Our center was not recommended and DD of Rs. 3000/- was returned to us. We have no complaints about the
                 processing of our application of AO or the procedure or regarding the refund.
                                                                       Seal and Signature of Authorized signatory of ALC
   12. Remarks by MKCL
        The information entered by MF on MKCL website is found to be correct/has been corrected as per this form. DDs of Rs.
        3000 and Rs. 500 have been deposited in the MKCL bank account in ________ _________ Bank __________ Branch on
        date ________



AO ALC Coordinator’s Signature                    MF Coordinator’s Signature                      SLC Coordinator’s Signature

								
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