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MSME-OI . Industrial Motivational Campaign Date: ---- At: -------- (qJ1Cf)~OI >fCl?('/REGISTRATION SHEET) fctR:r crt ~ ~ ? (~./ f.rnR wmi ) ~ S. 4fl1T ~ ~ q)T ~ q 1RfT Category (Please tick ./ mark) ~/~ ~m No. Participant Name & Address 'lf8;rr ~ ~ 3Rr 31('q ~ ~ Contact Telephone/ Signature 3Rr \ifIft1 ~ ~qsf ~ qsf Mobile No. Women SC ST OBC Minority PH Others General 1. 2. 3. 4. 5. 6. 7. 8. 9. I

fctR:r crt ~ ~ f.rnR wmi) - MSME DI-CHENNAI€¦ · Nameand Address of the Workplace/Company 12 q5'm cpr fucRurI xrfuIAmount Xii. IRs. Fees Details ~~ Cf>T ~: ~/~~: Mode of payment:

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Page 1: fctR:r crt ~ ~ f.rnR wmi) - MSME DI-CHENNAI€¦ · Nameand Address of the Workplace/Company 12 q5'm cpr fucRurI xrfuIAmount Xii. IRs. Fees Details ~~ Cf>T ~: ~/~~: Mode of payment:

MSME-OI .Industrial Motivational Campaign

Date: ---- At: --------(qJ1Cf)~OI>fCl?('/REGISTRATION SHEET)

fctR:r crt ~ ~ ? (~./ f.rnR wmi )~

S. 4fl1T ~ ~ q)T ~ q 1RfTCategory (Please tick ./ mark) ~/~ ~m

No. Participant Name & Address 'lf8;rr ~ ~ 3Rr 31('q ~ ~ Contact Telephone/ Signature3Rr\ifIft1 ~ ~qsf ~ qsf Mobile No.

Women SC ST OBC Minority PH Others General

1.

2.

3.

4.

5.

6.

7.

8.

9.

I

Page 2: fctR:r crt ~ ~ f.rnR wmi) - MSME DI-CHENNAI€¦ · Nameand Address of the Workplace/Company 12 q5'm cpr fucRurI xrfuIAmount Xii. IRs. Fees Details ~~ Cf>T ~: ~/~~: Mode of payment:

IMC

(Yvj"jCbxUI>fL!?f/REGISTRATION SHEET)Continuation SheeU .....

fcnfr cpt -x1 ~ ? (~,./ ffirA ~ ")~

S. '+fllT ~ ~ Cf)T ~ q LRITCategory (Please ./ tick mark) ~/~ 6ffiTaR

No. Name & Address of the Participant ~ ~ ~ 3Rl ~ ~"ffll1R1' Contact Telephone/ Signature\JfTfu" ~ ~q-.f ~ 3Rl q-.f

Mobile No.

Women SC ST OBC Minority PH Others General

I

Page 3: fctR:r crt ~ ~ f.rnR wmi) - MSME DI-CHENNAI€¦ · Nameand Address of the Workplace/Company 12 q5'm cpr fucRurI xrfuIAmount Xii. IRs. Fees Details ~~ Cf>T ~: ~/~~: Mode of payment:

~o~o~oto fc1c.nm ffl-QlR, ~ (mc=r) /MSME Development Institute, City (STATE)

13E1~dI.W,~ ~ Cf>14SfjJj/Entrepreneurship-cum-Skili Development Programm

~/Title:From _ ~/to _ X'.QWf /Place : _

Paste latestPP size

photograph I

of theparticipant

(4\JllClJ'i01 wr::l'/REGISTRA TION FORM)1, WT ~ cnchnT -;r[lf ~ 'tf ) ~/~/~

Name of the Participant (English) Mr.l MrsJ Miss

2, fTmT / -qfd cnT =rm ~

Father'sl Husband's Name Mr.

3, ~ cfi ~ 1RITPostal Address

I fiR I PIN I I I I I I4, ~~/~

Contact Telephonel Mobile No,

5, 3if'tTR ~ ~ ~ ~Aadhar Card Unique Identity No,

6. fcHr q<f ~ ~ ? 3'lj'q\RId 3lj'iiRlCl ~ ~ lff%c;rr FclCbC'li'l 'ffi11Rl

Category\1flfc1 \)'1""'1 \Jil R'l ~q<f ~ q<f

# PhysicallySC ST BCIOBC Minority Women Handicap General

(~ ./ f.rnA ~ ')# 3T(rtT-'ff~ (Minority) ~ en ~, ~, ~, ~ <:IT fucRsr ? ~ W ~:7. ~ I 31'T<]

Date of Birth / Age8. tTe:rfUrq) <Wmn

Educational Qualification9. ~,~~6

Experience, if any10 ~~

Present Occupation11 ~ COT fctcRurI ~/Amount ~, IRs.

Fees Details 1!~ Cf>T ~: ~/~ ~:Mode of payment: Cash /Demand Draft No.~:/ Dated~ COT -;:w:r: I Bank Name I

'ffl~ ~ c: {\II ~~~i$I ~ I List of Enclosures (qzqm f.1m;f ~ / PI. Tick mark) ./

1~ CPelT I~ I 31'T<]COT >fl1TUT q?f fcRfr 'C;CP $I fklOll rqCi '(91lOlll1R1

io" Certificate/DoS/Age Proof - Attested Photocopy of anyone

2tTe:rfUrq) <Wmn cf; >fl1TUT tr5r $I xi ,lOllfi1Ci '(9llOlll1R1Educational Certificate - Photocopy

3~ \ifTf'TI/~1~1R1 cf; >fl1TUT q?f $I xklOll rqCi tWlT >rfc'rSC/ST Certificate - Attested Photocopy

4~ >fl1TUT q?f $I xkl:l Ifi1C1 toP Il:l 111Rl (Fc! Cf) C1iII ~

~*~/Medical Certificate for PH-Attested Photocopy Signature of the Participant

5 3if'tTR ~ ~ $I xkl:lIfi1Ci toP I l:l 111fcl/Aadhar Card-Attested Photocopy ~q>lDate

Page 4: fctR:r crt ~ ~ f.rnR wmi) - MSME DI-CHENNAI€¦ · Nameand Address of the Workplace/Company 12 q5'm cpr fucRurI xrfuIAmount Xii. IRs. Fees Details ~~ Cf>T ~: ~/~~: Mode of payment:

~o~o~oto fctcrm m~, ~ (>Iicf) /MSME Development Institute, City (STATE)

~I:l'l ~ CflI4ctll"j/Management Development Programme

From- ~ Ito C'jq) x~ /Place : 1 .(cjujlCfl~OI }flR/REGISTRATION FORM)

Paste latestPP size

photographof the

participant Jftrtsn:T/Title :

1. ~ ~ ~ C!JT <fill ~ l:i ) ~/~/~Name of the Participant (English) Mr.l Mrs.l Miss

2. fimr I t@r em ~ ~

Father'sl Husband's Name Mr.

3. q"5llill~ cfi ~ 1RlTPostal Address

~IPINI I I I I I I4. ~~/~

Contact Telephone/ Mobile No.5. 31T'ClR CfiTi ~ ~ ~

Aadhar Card Unique Identity No.

6. fuJfr qrf ~ ~ ? 3ljxrRlC1 3ljXiRJCl ~ 31N ~ RtCflC'1iJI ~unm \ii 'i \iil fd ~cpf ~ cr<f

Category # Physically5C 5T BC/OBC Minority Women Handicap General

(~ ./ f.rnR ~ )

# 3RrtT-~~ (Minority).g ill ~, tmt, ~, ~ m ~ ? ~ 1T5i ~

7. ~ I ~ Date of Birth I Age

8. treTfUrcp <Wmrr Educational Qualification

9. ~, Experience

1fG-'Il1l I ~ cllCHWl10

Designation /Present Occupation

11Cf>l<f~ / ~lf4T <fiT ~ q 1fffiName and Address of the Workplace/Company

12 q5'm cpr fucRur I xrfu I Amount Xii. IRs.Fees Details ~~ Cf>T ~: ~/~~:

Mode of payment: Cash I Demand Draft No.~:/Dated

~ em ~: I Bank Name I~2T ~ ~'{~I~\iil ~ ~ lUst of Enclosures (crrm f.iw;r ~/PL Tick mark) ./

1~ CJ)WI~ I 3lTIj cpr wnuT q:;r ~ ~ ct't '<l,LllfQC1\JILlI~Aio" Certificate/DoB/Age Proof - Attested Photocopy of anyone

2~eTfiJTcp <W<:rm cf; wnur 1T3f ct't '<l,LlIfQC1 \JILlI~AEducational Certificate - Photocopy

3~ \ilTfTI I \ii1 \iil A cf; wnuT 1T3f ct't '<l,LlIfQC1t9TLIT ~SC/ST Certificate - Attested Photocopy

4~ wnuT 1T3f ct't '<l,LlIfQC1\JILli~A (Fcl Cf) ('1 ill -gg)MedicalCertificatefor PH-Attested Photocopy 'IfI1mff *~ /

5 31T'ClR ~ CfiTi ct't ~l~lfQC1 \JILlI~AI Aadhar Card-Attested Photocopy Signatureof the Participant~<l> !Date