CIEH Application - Nebosh Igc by hedongchenchen

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									                           CHARTERED INSTITUTE OF ENVIRONMENTAL HEALTH

                                        CIEH-APPLICATION FORM


  Please fill in the required details for registration along with a passport size photographs.

  Please write or type clearly:
                                                PERSONAL INFORMATION
Title                                               Mr         Mrs                 Miss          Dr         Others
(Please Tick (√) in the appropriate column)
First Name
(AS Per Id Proof )

Last Name
(AS Per Id Proof )

House Number              Street Name & Address


City                                     Country                  Postal Code                    Country of Residence

Date of Birth: (DD / MM / YY)                   Gender: Please Tick (√)                Nationality

                                                       Male               Female       Passport Number

Landline                                      Mobile Phone                         Official Number


E-mail


       Please submit a copy of any photo id Please Tick (√)

           Passport Copy          Driving License        Others     Please Specify:



                                              PROFESSIONAL INFORMATION
PRESENT EMPLOYMENT
DESIGNATION
TOTAL YEARS OF EXPERIENCE
OTHER HEALTH & SAFETY QUALIFICATIONS
ACADEMIC QUALIFICATION
MONTH OF JOINING
HOW DO YOU KNOW ABOUT US
SELF SPONSORED (Yes/No)
SPONSORING COMPANY
(Name of Company & Address to be mentioned)




                     2B, 4th Floor, Gokul Towers, No.7, C.P.Ramasamy Road, Alwarpet, Chennai - 600 018. F/MK/01/NEB-IGC
  Page 1 of 2        Tele: +91 44 4353 5335, +91 44 4211 3004.www.nistinstitute.com, info@nistinstitute.com
                         CHARTERED INSTITUTE OF ENVIRONMENTAL HEALTH

                                    CIEH-APPLICATION FORM


                                  Payment Mode: (Please tick the appropriate box)



        Cheque             Online Transfer               DD              Cash

     Payment details:
     Cheque/DD shall be provided in the name of NIST Institute Private Limited.
     Online transfer could be done to any of the bank accounts given below.




                                                    Bank Details


 HDFC Bank,Chennai                                            HDFC Bank, Bangalore
 Name of account – NIST Institute Private Limited             Name of account – NIST Institute Private Limited
 281, Mount Road Teynampet, Chennai - 600 018                 26, Ground floor, Akshaya Complex,Victoria
 A/c. No: 15862320000051                                      Layout, Bangalore 560 047.
 IFSC Code: HDFC0001586                                       A/c. No. 17512020000054
 Swift Code: HDFCINBB                                          IFSC Code: HDFC0001751
                                                               Swift Code: HDFCINBBBNG


TERMS AND CONDITIONS:

        Prior registration is required as there are only limited seats.
        Registration forms, copy of passport, passport size photos should be submitted on or before the last date of
         every batch.
     Cancellation should be confirmed in mail as scanned copy duly signed by the candidate or as a hard copy.
     Cancellation made 2 weeks before the commencement of training will not be refunded at any cost.
     Cancellation made 3 weeks prior to the commencement of training shall be returned 50% of the registration
         charges paid.
     Cancellation made before 4 weeks (and above) prior to the commencement of training will be deducted 12%
         (admin cost) of the registration charges paid.
     Any change in schedule must be informed before 2 weeks to the commencement of training to our institute
         either by e -mail or as a hardcopy duly signed by the candidate.
     NIST Institute Private Limited will cancel the training due to unavoidable situation. However, we will bring the
         rescheduled course to delegates’ notice in much advance without any additional charges and if necessary we
         have rights to change the tutor for any critical situation.
I declare that the information herein is true and correct to the best of my knowledge, I accept the Terms and
Conditions within the application document and I understand that this application is subject to approval by NIST.

Signature ______________________________________________ Date ________

     OFFICE USE ONLY


     Applicant No# __________     Reviewed by ______________       Date _______________ ACCEPT
     Month of joining:                                                                       REJECT


              2B, 4th Floor, Gokul Towers, No.7, C.P.Ramasamy Road, Alwarpet, Chennai - 600 018. F/MK/01/NEB-IGC
Page 2 of 2   Tele: +91 44 4353 5335, +91 44 4211 3004.www.nistinstitute.com, info@nistinstitute.com

								
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