DBM INSTITUTE
In Association with CSC Society Assam — Computer Training & Skill Development
Registered under the Societies Registration Act (XXI of 1860), Govt. of Assam
Phone: +91 94350 27116 • Email: dbminstitute@gmail.com • Web: www.dbminstitute.in
Please fill in BLOCK LETTERS using blue/black ink and submit to your nearest DBM Training Centre
| Form No. | Date | Centre Code |
Affix recent
passport-size photograph (self-attested) |
| Centre Name | Academic Session | ||
1PERSONAL DETAILS
| Full Name (as per ID proof) * | |
| Father's Name * | Mother's Name |
| Guardian's Name (if different) | Relation with Guardian ☐ Father ☐ Mother ☐ Husband ☐ Brother ☐ Other |
| Date of Birth * (D D / M M / Y Y Y Y)
|
Gender * ☐ Male ☐ Female ☐ Other |
| Aadhaar Number
|
Category ☐ General ☐ OBC ☐ MOBC ☐ SC ☐ ST(P) ☐ ST(H) ☐ EWS |
| Religion ☐ Hindu ☐ Muslim ☐ Christian ☐ Sikh ☐ Buddhist ☐ Jain ☐ Other |
Mobile Number * |
| Email Address | |
2ADDRESS
| Present Address (House No., Village/Town, P.O., P.S.) * | ||
| District | PIN Code | State |
3EDUCATIONAL QUALIFICATION
| Highest Qualification
☐ Below 10th ☐ 10th Pass (HSLC) ☐ 12th Pass (HS) ☐ Graduate ☐ Post Graduate ☐ Diploma ☐ ITI ☐ Other | ||
| Last Exam Passed | Board / University | Year of Passing & % |
4COURSE SELECTION
| Course Applied For * | Course Code | Duration |
| Mode ☐ Offline ☐ Online |
Preferred Batch / Timing | Preferred Training Centre |
DBM INSTITUTE • In Association with CSC Society Assam • dbminstitute.in • Page 1 of 2
DBM INSTITUTE
Student Admission Form — Page 2
Registered under the Societies Registration Act (XXI of 1860), Govt. of Assam
5BLOOD GROUP & DONATION
| Blood Group ☐ A+ ☐ A− ☐ B+ ☐ B− ☐ O+ ☐ O− ☐ AB+ ☐ AB− |
☐ I am willing to donate blood voluntarily
Willing donors are listed district-wise in our Community Blood Donor Directory to help citizens in need. |
6DOCUMENTS TO BE ATTACHED (self-attested photocopies)
☐ Recent passport-size photograph (also affix one on this form) MANDATORY |
☐ Aadhaar Card — copy of front & back MANDATORY |
☐ Last qualification certificate / marksheet MANDATORY |
☐ Caste / Category certificate (if applicable) IF ANY |
☐ Any other supporting document OPTIONAL |
7FEE DETAILS
| Particulars | Standard Fee (Ref.) | Amount Paid (₹) |
|---|---|---|
| Admission Fee (one-time) | ₹ 600 | |
| Tuition Fee (₹ 700 / month × ______ months) | as applicable | |
| Exam & Certificate Fee (one-time) | ₹ 200 | |
| TOTAL |
| Payment Mode ☐ Cash ☐ UPI ☐ Bank |
Receipt No. | Payment Date |
* Online (exam-only) course fees: up to 3 months ₹ 1,000 · up to 6 months ₹ 2,000 · up to 12 months ₹ 4,000. Fees are indicative and may vary by course — confirm with your training centre.
DECLARATION BY APPLICANT
I hereby declare that the information furnished above is true, complete and correct to the best of my knowledge and belief.
I understand that if any information is found to be false or incorrect at any stage, my admission is liable to be cancelled
without any refund. I agree to abide by the rules and regulations of DBM INSTITUTE and CSC Society Assam.
Place & Date
Signature of Parent / Guardian
Signature of Applicant
FOR OFFICE USE ONLY
| Student Registration No. | Batch Assigned | Date of Admission |
| Documents Verified By | Application Status ☐ Approved ☐ Pending ☐ Rejected |
|
| Remarks | ||
Authorised Signatory, DBM Institute
Centre In-charge (Signature & Seal)
DBM INSTITUTE • In Association with CSC Society Assam • dbminstitute.in • Page 2 of 2