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REFRESHER  COURSE
Application Form for  Renewal of Energy Manager / Energy Auditor Certification
Registration No :*
       EM-   
 
  
1. Caption :*
1a Name of the Applicant*   
2 FatherName*
  3.Present Address*
 
 
 
  City*
  Pin Code*
  State Name*
4.Permanent Address
City             
Pin Code      
State Name  
5. Date of Birth :*
6. Nationality* (Others Specify)
7. Sex*
8. Employment Status*
10 Present Company Address*
  Designation
  Company Name
  Company Address
 
 
  City*
  PinCode*
  StateName*
11.Contact Telephone Fax,Email
Office Phone
Fax
ResPhone
Email (Personal)*
Mobile (Personal) *
   
       
     
12. Total Work Experience*  Yrs Months
13. Course Centre *      
 Centre
14. Experience in the Energy field for the past three years  (May attach separate sheet)*  (Less than 200 characters (or less than 25 words) only to be used)
15. Number of Energy Audit carried out*     
16. Nature of work done for three years * (Less than 40 characters (or less than 5 words) only to be used in each text box)
Sl
No
Sectors in which you have conducted energy audits for the past three years Sector wise expertise (years against the name
 of sectors)
Energy audit
thermal utility
stystem
(list sectors)
Energy audit electrical utility system
(list sectors)
(a)Electiral
(list the name of the instruments used during
audit)
(b)Thermal
(list the name of the instruments used during
 audit)
1.
2.
3.
4.
5.
6.
17.
Details of training programme /seminars/ workshops attended during the last 3 years in the field of  energy efficiency/ energy audit (May attach separate sheet)/
*  (Less than 200 characters (or less than 25 words) only to be used)

     
                     
18.   Amount (Rs)      
 

Kindly write legibly your Name and Father's Name in Hindi for issuing Final Certificate in bilingual after taking print out of the application
Declaration by the Candidate
I hereby declare that all the information given in the application form and enclosures are true to the best of my knowledge. I agree to the condition that if any information or any statement is found to be incorrect, my registration to the examination would be cancelled. I also understand that it is my responsibility to cross check information from the websites as mentioned in the prospectus for the allotted examination centre and issue of hall ticket. I shall inform NPC Chennai about any  change in my mailing address, telephone number and e-mail ID, if any, at the earliest. I also abide by the examination scheme and conditions as mentioned in the prospectus.
Place
Date