CCC EXAMINATION FORM

ADDRESS:
   BATCH SERIAL
(For Office use only)
Recent Photograph
35mm x 45mm
Attested by a
Gazetted Officer
or
 Bank Officer
or
Incharge – DOEACC
Accr. Instt.
DOEACC SOCIETY
Electronics Niketan, 6, CGO Complex, New Delhi – 110 003
Phone:011-2436 3330-02, 2436 6577, 79, 80, FAX:011-2436 3335
Email:ccc@doeacc.edu.in, Web site: http://www.doeacc.edu.in
EXAMINATION APPLICATION FORM - CERTIFICATE COURSE ON COMPUTER CONCEPTS –(CCC)
(READ ENCLOSED INSTRUCTIONS CAREFULLY BEFORE FILLING UP THIS FORM)
BOX F.
Month & Year of Examination
1. NAME - IN CAPITAL LETTERS  
2. FATHER’S NAME – IN CAPITAL LETTERS
3. MOTHER’S NAME – IN CAPITAL LETTERS
BOX E.     SIGNATURE OF CANDIDATE
4. DATE OF BIRTH     (in Christian Era)
D D M M Y Y Y Y
5.    SEX
Cost Rs. 20/-
Recent Photograph
35mm x 45mm
Unattested copy of
Photograph pasted in Box
A.
 Ο   MALE   Ο   FEMALE
                       Darken appropriate box
6. HIGHEST QUALIFICATION: (Darken appropriate box AND attach Attested copy of the Certificate, in respect of the Box darkened)
Ο Below 10
th
 Ο 10
th
 Pass Ο 10+2 Ο 10
+ITI Ο Polytechnic Diploma       Ο Graduation or higher
7. RESIDENCE DETAILS OF CANDIDATE - IN CAPITAL LETTERS
th
CITY: PIN CODE
STATE:
7.1. CONTACT DETAILS
PHONE NO.
EMAIL ID
8. INSTITUTE DETAILS- IN CAPITAL LETTERS
8.1 E-PROV. NUMBER:
9 9
NAME:
ADDRESS:
For Office use only
  BOX C.
  BOX A.
BOX B. STATUS OF CANDIDATE
Ο
Ο
DIRECT
ACCR. INSTT
BOX D. FEE DETAILS
DD NO
DD DATE
AMOUNT (in Rs.)
BANK
Ο
Ο
GOVT. RECOG SCHOOL / COLLEGE
OTHERS
       STATUS OF INSTITUTE:   Ο  ACCR. INSTTT       Ο GOVT. RECOG.SCHOOL/COLLEGE           Ο OTHERS
9. CENTRE CHOICE         First Choice      Second Choice
CITY CODE NAME CITY CODE NAME
10. OCCUPATION:   (Darken the appropriate box)
Ο Govt. Employed Ο Govt. undertaking Ο Self Employed    Ο Other (Please Specify) . . . . . . . . . . . . . . . .
11. CATEGORY: (Darken the appropriate box)
Ο General      Ο Scheduled Caste Ο Scheduled Tribe    Ο O.B.C.    
Ο Handicapped      Ο Other Please Specify) . . . . . . . .
12.  WHETHER APPEARED PREVIOUSLY IN ‘CCC’ EXAM YES/ NO
If YES, give details of immediate LAST EXAM only        
MONTH:               YEAR:         ROLL NO.:
13. DECLARATION:
I                                                                            S/o /D/o                                                                 (Father’s  name) hereby declare
that, all the particulars stated in the application, are true to the best of my knowledge and belief. I agree to abide by the
rules  and  regulations  of  DOEACC Society  and  also  to the  decision  of  the Examination  Authority,  regarding  my
admission to the examination. I have noted that the Examination Authority has the right to withhold my result even after
my appearing in the Examination in addition to any other action as may be deemed fit  in the event of any of the
statements made above being found incorrect. I have noted that, I might be required to appear in the examination at
any other centre not specified under centre choice column above.
Place:
Date:  Signature of the Applicant
14. TO BE FILLED BY INSTITUTES / GOVERNMENT RECOGNISED SCHOOLS / COLLEGES, CONDUCTING
‘CCC’ COURSES, ONLY
      (Refer to the Guidelines for Institutes)
Certification:
Certified that the applicant is / was a bonafide student, of  DOEACC - Certificate Course on Computer Concepts
(CCC) during the session from ________________ to ________________ at this institute and has completed course
before the examination, and an amount of Rs. 340/- has been received from him/ her.
Signature:
Name:
Designation: Institute Seal with Address
CHECK LIST OF THE ENCLOSURES
ITEMS Please Darken
 Demand Draft (Examination fee)
 Attested Photograph
 Unattested Photograph
 Attested copy of Mark sheet of Highest Qualification Obtained by the
Candidate
appropriate Box
Ο
Ο
Ο
Ο
Cost Rs. 20/-