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APPLICATION FORM FOR AFFILIATION

Information About Institution (All fields are mandatory!)

Applying For   Authorized Learning Center   District Coordinator
District Coordinator Code Affiliation Type
Technical Experience in this Area which makes you eligible for District Coordinator Program
Institute Name
Institute Address
City
District State
Pin Country
Mobile
+91
Email
Status of Institution  Trust  Society  Other Year of Establishment

Information About the Chief Executive/Principal/Director of the Institute

Name Photo
Designation/Position Education Qualifiation
Professional Experience D.O.B
Check this box if Institute Address and Head of the Institute Address are the same.
Address of Head
City
District State
Pin Country
Mobile
+91
Email

Infrastructure Facility

PARTICULARS NO.OF ROOMS SEATING CAPACITY TOTAL AREA (Sq.Ft.)
Staff Room
Class Room
Computer Lab
Reception
Toilets
Any Other
Payment Mode   Demand Draft (DD)   Online Payment