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ONLINE APPLICATION FORM

First Name: Pavan Kumar Surname: Bhagavathula Address for correspondence: Plot No 79 sector 52Near Arawali Apartments City: Noida Telephone No: Res: Sex: Male Marital Status: Married E-mail: pavankumar001@gmail.com Latest Qualification: M.Tech Work Experience: Name of the Organisation Voith Hydro Pvt Ltd Kirloskar Brothers Ltd Sanghi Polysters Ltd previous company Reference Source: Others Other Source: Manisha SinghOther Source: Course Applied for: Post Graduate Diploma in Energy Management Specialization: Select Undertaking by the student: I agree to abide by rules and regulations of MITSDE. I have noted that fees once paid will not be refunded. I agree not to divulge any information of training program. Stated course fees are valid for applied academic period only. Supporting Documents: Mark sheet / Degree certificate http://www.mitsde.com/Applicationform.asp 2010-05-25 No. of Years 3 1.6 1.0 Designation Dy.Manager Associate Manager Trainee Engrr Date of Birth: Off: Mobile: 9971586100 State: Uttar Pradesh Pin: 201307

Page 2 of 2 Two Photographs Experience Certificate (for working student) Note : All fees should be paid by D.D. drawn in the favour of "MIT School of Distance Education payable at Pune. Full Course semester fees should be paid 10 working days before commencement of the course at the address mentioned below. Course material issued to students will be proprietary of MITSDE. Unauthorised reproduction is not allowed. If done so, it will be violation of Copyright Act. MIT SCHOOL OF DISTANCE EDUCATION 1st floor, Unit W - 105, World Peace Centre 124, Paud Road , Kothrud, Pune 411038. Tel: (020)25465882, (020)25465883 Fax: (020)25454918, (020)25442770 Toll free No: 1800 - 233 6376 e-mail: admissions@mitsde.com Thank you for your Application. You are requested to send following documents by courier within seven days, so that we can process your application form. List of Documents 1. Degree / Diploma certificates (Attested Xerox copies by gazette officer / notary/ college principal) 2. Two copies of recent passport size colour photographs 3. Demand Draft in favour of MIT School of Distance Education payable at Pune Please mention your complete name & course applied for behind the dd. (Please refer site for fee structure). 4. Three years experience/Service certificate (after completion of diploma) in case of diploma holders. 5. Copy of online application form 6. Xerox of your pan card/driving license 7. For NRI students cop of Visa/Passport is rquired. Online application will be vaild till 3 weeks from the date of submission.

http://www.mitsde.com/Applicationform.asp

2010-05-25