APPLICATION FORM

Please fill in the required details for registra on along with 2 passport size photographs.
Please write or type clearly:

Please Tick (√) in the appropriate:

PERSONAL INFORMATION
Title (Please Select in the appropriate column)
Mr Mrs Miss Dr Others

✔
Given Name (As Per Id Proof ) VENKATA RAMI REDDY Surname (As Per Id Proof ) KAMUJULA
Please ck the appropriate ID proof to be enclosed (√) Passport Copy Driving Licence ✔ Aadhaar ID Please Specify:

House Number : Street Name & Address:

City: Country : Postal Code: Country of Residence :

NARASARAOPET INDIA 522601 INDIA

Date of Birth: (DD / MM / YY) Gender: Please Tick (√) Na onality: Passport Number :

01/05/1990 .
✔ Male Female INDIAN
Landline: Mobile Number: Official Number:
9700700357 8328693482
Emergency Contact Number: E-Mail_ID:
9000325510 KAMUJULA36@YAHOO.COM
Please ck the appropriate ID proof to be enclosed (√)
SPECIAL NEEDS OF CANDIDATES
If “YES”(√) provide appropriate Proof
If “NO”(√) men on “Not Applicable”
Do you have any permanent or long term disabili es or temporary
disability in performing certain types of work? Please Specify:
YES ✔ NO

Do you have any medical condi on or specific learning need?

Please Specify:
YES ✔ NO
Is English your second language? What is your first language?
Please Specify: TELUGU
✔ YES NO

Page 1 of 4 Flat no.203, 3rd Floor, Almas Plaza, No.10-3-304/7/203, Humayun Nagar, Next to Yes Bank, Hyderabad-500 028 F/MK/01
Toll Free : 1800 103 2442 Website: www.nis ns tute.com E-Mail: info@nis ns tute.com Tele: 040 66689777
 APPLICATION FORM

INFORMATION

PRESENT EMPLOYMENT(Name of the Company) L&T CONSTRUCTIONS

DESIGNATION ASSISTANT MANAGER EHS
TOTAL YEARS OF EXPERIENCE 7
OTHER HEALTH & SAFETY QUALIFICATION DIPLOMA IN INDUSTRIAL SAFETY
ACADEMIC QUALIFICATION B.TECH (EEE)
NAME OF THE COLLEGE TIRUMALA ENGINEERING COLLEGE (JNTUK)
MONTH OF JOINING MARCH-2019
SELF SPONSORED (Yes/No) YES
SPONSORING COMPANY (Name of Company & Address to be mentioned)

OUR PRODUCTS

Please select the courses you are applying for

IOSH MANAGING SAFELY TRAINING DATE:

NEBOSH ✔ INTERNATIONAL GENERAL CERTIFICATE (IGC)

TRAINING DATE:
18 TO 29 MARCH 2019
Bri sh Safety Council RISK ASSESSMENT FIRE SAFETY
TRAINING DATE: TRAINING DATE:

COURSE MODE(√)
E-LEARNING CLASSROOM TRANING
✔

Page 2 of 4 Flat no.203, 3rd Floor, Almas Plaza, No.10-3-304/7/203, Humayun Nagar, Next to Yes Bank, Hyderabad-500 028 F/MK/01
Toll Free : 1800 103 2442 Website: www.nis ns tute.com E-Mail: info@nis ns tute.com Tele: 040 66689777
 APPLICATION FORM

How do you know about NIST?

✔ Website Google Search ✔ Mail

SMS Reference Adver sments

Exhibi ons Facebook If Others Pl men on:

EXAMINATION DETAILS (IOSH MS ONLY)

Please indicate the unit examina on/s for which you are registering. *Please Tick (√)+

IOSH MS Exam Date PROJECT Exam Date

EXAMINATION DETAILS (NEBOSH IGC ONLY)

Please indicate the unit examina on/s for which you are registering. *Please Tick (√)+

✔ IGC1 Exam Date ✔ GC 2 Exam Date ✔ GC 3 Exam Date

TO BE FILLED BY NEBOSH IGC, IOSH MS - RESIT CANDIDATE ONLY

(Mandatory if you a end or register with NEBOSH through any course provider)
Course Provider Student Number Date/s of Previous Si ng

Cer ficate Name Confirma on

I read and agree to the name to be displayed as per my given id proof ( ) K VENKATA RAMI REDDY
Signature of the Candidate

Payment Mode: (Please ck the appropriate box)

Cheque ✔ Online Transfer DD Cash Loan

Payment Details: Cheque/DD shall be provided in the name of NIST Ins tute Private Limited.
Online transfer could be done to any of the bank accounts given below.

Page 3 of 4 Flat no.203, 3rd Floor, Almas Plaza, No.10-3-304/7/203, Humayun Nagar, Next to Yes Bank, Hyderabad-500 028 F/MK/01
Toll Free : 1800 103 2442 Website: www.nis ns tute.com E-Mail: info@nis ns tute.com Tele: 040 66689777
 APPLICATION FORM

BANK DETAILS
Payment Mode: Online Transfer / Direct Cash Deposit / DD / Cheque
Account Name: NIST Ins tute Private Limited
Account
Bank Branch Account Number Account address SWIFT CODE
IFSC CODE
HDFC bank, SGM Mall 12-2-825
HDFC Mehdipatnam 03652560001204 & 826 Mehdipatnam Bus Stop, HDFC0000365 HDFCINBB
Hyderabad – 500 028
SBI bank, New No.4, First Street,
SBI Abhiramipuram 32609222030 SBIN0012749 SBININBB
Abhiramipuram, Chennai - 18.

TERMS AND CONDITIONS:

Ø Prior registra on is required as there are only limited seats.

Ø Registra on forms, copy of passport, passport size photos should be submi ed on registra on me itself
Ø Cancella on should be confirmed in mail as scanned copy duly signed by the candidate or as a hard copy.
Ø Course cancella on or batch transfer on or a er 3 weeks before the commencement of training date,
payment will not be refunded at any cost
Ø Cancella on made 4 weeks prior to the commencement of training will be deducted 15% (admin cost) of the
total course fee.
Ø Candidate discon nued during the training will not be refunded at any cost and they are subjected to pay the
agreed amount.
Ø Any change in schedule must be informed before 4 weeks to the commencement of training to our ins tute
either by e -mail or as a hardcopy duly signed by the candidate.
Ø NIST Ins tute Private Limited will cancel the training due to unavoidable situa on. However, we will bring the
rescheduled course to delegates’ no ce in much advance without any addi onal charges and if necessary we
have rights to change the tutor for any cri cal situa on.
Ø Any cancella on made by the company will be refunded without any deduc on. For any cancel la on or batch
transfer we will communicate 1 week prior to the closing date.
Ø Payments should be made only to NIST Bank Account Details. NIST is not responsible if the payment is done to
any individual account.

I declare that the informa on herein is true and correct to the best of my knowledge, I accept the Terms and
Condi ons within the applica on document and I understand that this applica on is subject to approval by NIST.

Signature: Date:

OFFICE USE ONLY

Reference No:_____________________________ Reviewed by :______________________________Date:_______________________

Month of joining: _________________ Approved by :____________________________ Designa on: _________________________

Page 4 of 4 Flat no.203, 3rd Floor, Almas Plaza, No.10-3-304/7/203, Humayun Nagar, Next to Yes Bank, Hyderabad-500 028 F/MK/01
Toll Free : 1800 103 2442 Website: www.nis ns tute.com E-Mail: info@nis ns tute.com Tele: 040 66689777
 Student Learning Agreement
Training Terms and Conditions:

1. Any examination schedule to be confirmed only through email. Verbal information cannot be accepted.
2. Candidates should follow Formal Dress code.
3. 100% attendance is mandatory on each training day unless exceptional circumstances arise or you have
previously informed the tutor of your inability to attend.
4. Candidates are expected to maintain decorum in the classroom.
5. Undertake sufficient private study to maintain progress on your course. This will involve doing your
own research in line with the syllabus guide.
6. Candidates are expected to provide id proof with appropriate name and initials, as required in the
certificate. If any name change is requested at later stage of examination registered date, replacement
fees are applicable as denoted by the organization. Refer to the given link: NEBOSH Replacement
Certificate Policy
7. Candidates are required to settle the agreed amount during the training and before appear the exams.
8. If you pay your course fee by installments, ensure that all course installments are paid on time before
Exams.
9. Candidate discontinued during training will not be refunded at any cost and they are subjected to pay
the agreed amount.
10. Payment will not be refunded at any cost If Course cancellation or batch transfer request made after the
registered batch closing date.
11. Candidates who had registered through loan will not entitle for Cancellation or Refund. However, batch
transfer is possible before the closing date.

Examination Policy:

1. Carry original ID proof [Passport/Driving license/Voter ID] with correct spelling to enter in to
examination hall. You will be not be allowed without original id poof to write the exams and
marked absent.
2. Do not carry any unauthorized material before entering the Examination hall.
3. Listen to invigilator instructions, for hall ticket, id proof & writing the answer booklet.
4. Raise your hand for any query, do not try to obtain any assistance and do not disturb other candidates.
5. Refer to the dictionary to avail 30 minutes extra time if your mother language is not English
6. Keep your answer sheets, question paper and admission voucher secure, be seated until the paper are
collected.

Malpractice Policy

1. Candidates should not involve in any malpractice in resubmitting the projects from their friends or
colleagues and copied from internet as it clearly reflects your knowledge and abilities.
2. Students who commit plagiarism by submitting work that is not theirs will be removed from their
course immediately, without refund of fees since NEBOSH have a zero tolerance policy on plagiarism
and cheating.
3. Any violation in examination policy will be considered as malpractice which may leads to invalid
results and candidate needs to face further consequences. Kindly follow the examination protocols.
Refer to the given link: NEBOSH Malpractice Policy

Reasonable Adjustment Policy:

 1. We Deal with any difficulties promptly and fairly.
2. NEBOSH is required to take reasonable steps to overcome that disadvantage with a Braille paper which
would be a reasonable adjustment for a visually impaired person who could read Braille candidates
under Equality Act 2010.
3. Special consideration can be applied for candidates who are disadvantaged by temporary illness,
bereavement, injury or adverse circumstances that arose at or near the time of assessment.
4. Refer to the link for more details: Reasonable Adjustment policy

Project Submission:

1. Project should be completed by the candidate based on the workplace/site inspection and with their
experience in the format and by the method according to the awarding body guidelines.
2. Keep in contact with your tutor or HO by email to ask for queries during your preparation, with mutual
understanding upon his or her time.
3. After submission of projects it will not be reviewed & also we would not provide any feedback to the
candidates, we will only acknowledge the receipt of the project.
4. Candidates are ensure the documentation is up to date & correct version as per NEBOSH website
5. Candidates are requested to submit the project with names and signatures all completed including
declaration form within the specified timeframe.

EAR Policy:

1. NEBOSH supports the right of students and/or accredited course providers to enquire about a result, to
appeal against the outcome of that enquiry and has procedures to ensure that such enquiries and
appeals are dealt with in a thorough and equitable manner.
2. Refer to the link below: NEBOSH EAR Policy
NEBOSH General Terms & Conditions

1. NEBOSH remove candidate from the course if candidate behavior is abusive or unreasonable. They
have a zero tolerance policy on rudeness and plagiarism.
2. If, for any reason, you are unable to attend exams, you must give prior notice before closing date. If not,
a charge will be made to cover expenses as noticed by NEBOSH.
3. Students with no prior experience are recommended towards lower level safety courses prior to
acceptance of IGC and minimum NEBOSH English standard is required to attend the courses.
4. Refer to the below link:
NEBOSH General Terms and Conditions

Course Provider Responsibilities

NIST will:

1. Deliver training in line with Awarding Body syllabus.

2. Enroll you with NEBOSH and register you for exams
3. Encourage you during your studies.
4. Provide constructive and individual feedback on your progress.
5. Operate an equal opportunities policy. Refer to the given link Equal Opportunity Policy
 6. Offer chargeable revision session to prepare you for the NEBOSH Exams.
7. Personal tutor will be assigned for NEBOSH IDIP Unit D to communicate on one-to-one basis.
8. Only provide tutorial support for our course materials and directly related issues: careers / job / work
advice.
9. Remind you if you have fallen behind with any course fee installments and only lapse your tuition if
you have failed to respond to two reminder emails. We will then give you written notice that we have
lapsed your tuition and will archive your records. You may rejoin the course at any time if your course
fees are brought up to date and on payment of an administration fee.

Complaint Policy and Procedures

1. The Policy complies with the requirements on raising complaints as an expression of dissatisfaction by
one or more individuals about the standard of a service, action or lack of action by the institution.
2. Contact us to know more about the complaints policy and procedures

Candidate Responsibilities

1. Read the relevant course information pages on the NEBOSH website to establish that the course is
appropriate for you.
2. Mock tests should be taken seriously and no absenteeism is encouraged.
3. Ensure that your IT and software equipment works efficiently for any online support
4. Ensure to take your classes and examinations seriously as you are responsible for your results. Either
NEBOSH or NIST will not take sole responsibility of its outcome.
5. Attend for examinations for which you have been registered.
6. Notify us in advance if you are going to lapse from your course, and tell us the duration. By failing to
communicate with us for 12 months, you are effectively removing yourself from the enrolled course
under this Agreement. You may rejoin the course, but a fee of up to 100% of the original course fee
will be charged.
7. To fill the student feedback in the appropriate form
8. Understand all the NEBOSH policies, terms & conditions.

I have read all the instructions before taking the registration for the training program. I accept the terms and
conditions and follow the same.

Thank you.

Signature: Date:
 For office use only

Agreed fee

Amount paid initially

Balance to be paid & date

Receipt No

DC No

Counselor Name