PIEM

Course & Personal Details :-

Name of the Course Applied for:

Name in Full : Shri/ Smt / Kum :

Father's Name :

Mother's Name :

Address for Correspondence

Pin :-

Telephone No.

Mobile No.
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E-mail ID

Permanent Address

Pin :-

Marital Status
UnMarried Married

Date of Birth :

Gender
Male Female

Degree

Name of Institution

University Board

Year of Passing

Percentage [%]

Other Qualification:

Name of Employer

Date of Joining

Date of Leaving

Nature of work

Designation

Examination Option:

Class Room System

Online Test

Exam from Home

Total Fee Paid Amount Photo: OTP Verify