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TM

Institute: Poonam Chambers 5th Floor, A Wing Byramji Town, Chhindwara Road, Nagpur. Maharashtra India- 440013. Ph: 0712 - 3922230 M.: 90 960 88 419, 9096088526 Email: info@synergemindia.com

ISO 9001 : 2008 CERTIFIED

RECOGNIZED

Training

Recruitment

Human Resource Development

Engineering Consultancy

SYNERGEM

Recognized by Central Electricity Authority (Under Ministry of Power, Govt. of India) No. 6/71/2010 - HRD/2789

APPLICATION FORM
For Admission to PG Program in Power Plant Engineering
Either TYPE or filled by hand writing using Capital Letters 1. FULL NAME :
(First Name) (Middle Name) (Surname)

2. DATE OF BIRTH : 3. GENDER : MALE/FEMALE 4. MARITAL STATUS : 5. FATHER'S NAME : 6. PERMANENT ADDRESS :

3. PLACE OF BIRTH :

Paste your self attested Photograph here

6. NATIONALITY :

STATE : 7. Please provide : Mob: E-mail address :


8.

PIN CODE : Landline No:

Program Applied :

One Year PG Program in Power Plant Engineering (Full Time) One Year PG Program in Power Plant Engineering (Executive Program - Distance) 2 Weeks 210 MW PC based Simulator Training Program
(Please TICK one only)

9 EDUCATION DETAILS Sr. No. Discipline 10th 12th Diploma Engineering Additional Training Branch Stream Name of School/ College/ Institute Board/ University Year of Passing Overall % / Degree % / Grade Average (if degree completed)

10. Industrial Training Sr. No. Year Duration (Days) Company Details about training

11. Working Experience (latest three only) Sr. No. Company Total year of experience From (Year) To (Year) Designation Work Profile

12. Additional Information (Achievements, Interests etc):

13. Declaration by the applicant: Certified that all information provided by me in this form is correct to the best of my knowledge and belief. I understand that any willful misrepresentation of facts will result in my admission being cancelled / dismissal from the Institute. If admitted, I shall abide by all the rules and regulations of the Institute. Date : Place : I agree Terms and Conditions Signature of Candidate

14. Declaration by Parent/ Guardian (Not to be filled by sponsored/ executive training candidates) In the event of Mr./Ms. Son/ daughter/ ward being admitted, I hereby give an undertaking to pay regularly all admissible dues to the Institute and Hostel till the completion of his/ her studies. I also undertake the responsibility for his/ her good conduct. Date : Place : I agree Terms and Conditions Signature of Parent/Guardian

Important information for candidates A) List of Documents to be attached (Self Attested Photocopy) Date of Birth Certificate or High School (Class 10th) Certificate with DOB Mark sheet of 10th, 12th, Diploma, Engineering Degree, Training Certificates 3 Passport size photograph with name written on back side Experience Certificate - Only for experienced candidates Take a print out of this application form, attach necessary documents as required and send the completed application form with required DD as application / course fee, drawn in the name of 'Synergem' payable at Nagpur to the address given below through Courier or Speed Post/ Registered post. The completely filled up form should reach the following address To, The Principal Director, Synergem Power Plant Training Institute 5th Floor, A Wing, Poonam Chambers, Bairamji Town, Nagpur 440013 Maharashtra INDIA

B)

C)

If you have any difficulty in filling the form or require additional information, kindly contact for a step by step guidance at +91 9096088526, +91 9096088419 Or mail us at info@synergemindia.com

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