Course Applied For

Personal Information
Salutation

Mr.

Ms.

Mrs.

Name*
Date of Birth*

Category Code 1

SC

ST

M/
F
OBC

MBC

GE
N

Father/ Husband/ Caretaker

Name
Religion
Permanent Address*

Please Affix
Candidate's

Taluka / Taluk / Block

Recent Photograph

District
State
PIN
Communication Address

Taluka / Taluk / Block

District
State
PIN
Contact Nos.

Mobile*

Res

E-Mail ID
Educational Qualification *

Professional Qualification*

Pre Training Status

Fresher

Experienced

Employment Status

Employed

Unemployed

Aadhar Number & Bank Account Details

UIDAI/ Aadhar Number**
UIDAI/
Aadhar Enrollment
Number (in case UIDAI/Aadhar
not issued)**

**Mandatory fields and self attested Copies of supporting documents to be submitted along with this Registration Form
For use by Training Centre only

Selected - Y/
N

Training Center Address &

Location
Course Name
Skill Code
Course Start Date

Name
of
Counselor

Job Role
Course End
Date
Interviewer/

Name
&
Signature
of
Center Incharge

Creative Brains India, F-2/6, Ambar Complex, MP Nagar, Zone-II, Bhopal-11, MP India Visit Us: www.creativebrainsinida.co.in