Application Form

Course *

Branch *

Specialization Please select a specialization.

Date of Admission *

Date of Birth *

Student Name *

Father Name *

Mother Name *

Gender *

Category *

Religion

Aadhaar No *

Permanent Address *

Present Address *

Email ID *

Contact No *

Student Documents Checklist

10th Certificate

10th All Mark Sheet

+2 / Diploma Certificate

+2 / Diploma All Mark Sheet

Degree Certificate

Degree All Mark Sheet

Leaving Certificate

Passport Photo (2 Nos)

Aadhar Card (Front & Back)

Residence Certificate

Income Certificate (if available)

Caste Certificate (if available)

Entrance Attend (if available)

Registration Fee Payment Slip

Any Request Letter Copy (Finance Scheme / Discount etc.)

Qualification (Row 1 is mandatory)

Year of Passing	Board / University / Council / Institution	Subject Taken	Total Mark	Mark Achieved	Grade / %
Year of passing (Row 1) is required. Enter a valid year (e.g. 2020).	Board (Row 1) is required.	Subject (Row 1) is required.	Total mark (Row 1) is required. Total mark must be a number (0-9999).	Mark achieved (Row 1) is required.	Grade/Percentage (Row 1) is required.

I hereby declare that — All the information filled in this information form are true, complete and correct best of my knowledge and belief. I have gone through the syllabus and all the rules & regulations of the board / institute / university / autonomous body regarding this examination. If any information found false in my admission form, I shall be held responsible for cancellation of my admission at any time and stage. After gone through all this information I also declare that in future I never claim against the board / institute / university / autonomous body for any reason. If I do so then court shall disable me. I have also gone through the constitution of the board / institute / university / autonomous body. RSSIMSC / CISE is a study center / information center working for different educational institute / board / university / autonomous body etc.

My selected board/institute/university/autonomous body name is: *

Click here for Payment Details & QR Code

Account Name: Capital Industrial Safety Engineering

Account Number: 924020002370061

Bank Name: Axis Bank

IFSC Code: UTIB0002053

Paid Amount *

Transaction Proof / UTR / Reference ID *

Regd. Office — Kalpana River View Complex, Block-A / 4th floor, Flat No. 409, Bankual
Campus 2 — Kendrapara, Duhuriya, Bhubaneswar, Pin-751002
Email: rssimsc@gmail.com | Web: www.cise.co.in | Ph: 7894297888