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APPLICATION FORM FOR AFFILIATION

Information About Institution (All fields are mandatory!)

Applying For   Authorized Learning Center
District Coordinator Code Affiliation Type & Fee
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