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INSTITUTE

BT Institute of Journalism and


Mass Communication Pvt. Ltd.
Regd No.: U80904MH2012PTC226186

607, Vindhya Commercial Complex, Near UTI, Sector - 11, CBD-Belapur, Navi Mumbai - 400614 Tel.: 22-41276901
Email: bntiwari.darc@gmail.com Website: www.btnewsbroadcasting.in

No.____________
Application Form for Workshop
1.

Full Name of Application (in Block Letters)___________________________________________

(As mentioned in your Class X Certificate)

2.

Fathers Name __________________________________________________________________

(As mentioned in your Class X Certificate)

3.

Mothers Name _________________________________________________________________

(As mentioned in your Class X Certificate)

4.

Date of Birth _______________________ 7. Parents Occupation ______________________

(As mentioned in your Class X Certificate)

5.

Parents Annual Income (Per Month) Rs. ________________________________________ P. A.

(Please attach the Recent proof of Income)

6.

Permanent Address (Complete) ___________________________________________________

_______________________________________________________________________________

________________________________________________________ Pin Code _______________

Phone No. (Resi) with STD Code_______________________ Mobile _______________________

7.

Correspondence Address (Complete) _______________________________________________

_______________________________________________________________________________

_______________________________________________Mobile No. (Parents)_______________

8.

Eligibility (Please Tick only)

(a) Graduatation/HSC with Maths (10+2+3) (b) Graduation / HSC without maths (10+2+3)

Aggregate % Obtained _______ % in 10+2 / Graduation for all three years (if any)

9.

Extra Curricular Achievements

1. _____________________________________________________________________________

2. _____________________________________________________________________________

3. _____________________________________________________________________________

10. Payment Details (We do not accept any payment by cash/cheque)


Name of the Bank ____________________________________ Branch _____________________

DD No. _______________________ Date ________________ Amount Rs. ___________________

11. Undertaking by the Applicant


Future we certify that the information furnished above is true to the best of our knowledge and
belief. We understand that if any information is found false / incorrect at any stage we will be
responsibile for that and the candidature / admission to the course shall be cancelled without
any refund of fees.

Signature of the Applicant ________________ Name of the Applicant __________________________


Note:
Fill the application form neatly and in legible Hand-writing. The form should be submitted along with
all the documents within situlated time.
(Please enclose self attested copies of certificates and the Mark Sheets / Address Proof / Photo ID Proof)
Rules & Regulation:
Registration - A Candicate can apply for only one programme for one session.
Incomplete Application Form:
Incomplete Admission Form will be rejected by the Company (BT Institute of Journalism & Mass
Communication Pvt. Ltd) without any information to be candidate. Therefore the candidates are
advised they fill the relevant details very carefully and attach the self attested copies of the required
certificates, photo ID and address proof.
Duration of the Workshop:
The minimum duration for the completion of workshop is 12 hrs. In this duration no additional fee
shall be charged from the concerned student.

Refund of Fee:
Fees once paid will not be refunded / transferred at any circumstancaes and also will be considered for
any other program / workshop of BT Institute of Journalism & Mass Communication Pvt. Ltd.
Note:
Any matter / dispute will be subject to Mumbai Jurisdiction.

Signature of Applicant ___________________________________