You are on page 1of 3

KnoWerX Education (India) Private

Limited
Examination Registration Form (Version 2011.02)
P
s
Name you desire on your certificate: Saroj Kumar Nayak w
Gender: Male m
to
How you would like to be F
addressed/called? Mr. n
KnoWerX identification number: c
<
APICS identification number: 1752402 id
Date of birth - Day: 20 y
Date of birth - Month: 2
Date of birth - Year: 1986
Religion (to greet) (optional): Hinduism
Highest qualification level: Master
Academic discipline: Business
Year qualified: 2012
Qualified from: National Inst of Industrial Engineering
Other:

Address: Near L&T Powai, Vihar Lake; Mumbai - 87 (India)


Your current field of work:
Home address - Line 1: House No - 16, Gopabandhu Sarani
Home address - Line 2: Kalinga Nagar, P.O. - Telinipara
Home address - City: Bhadreswar, Dist - Hooghly
Home address - State: West Bengal
Other:
Home address - Postal code: 712125
Home address - Country: India
Home phone 1 - Country: India
Home phone 1 - City/area code: 33
Home phone 1 - Number: 26337018
Home phone 2 - Country:
Home phone 2 - City/area code:
Home phone 2 - Number:
Home/personal mobile 1 - Country: India

Home/personal mobile 1 - City/area code:


Home/personal mobile 1 - Number: 9769656842
Home/personal mobile 2 - Country:

Home/personal mobile 2 - City/area code:


Home/personal mobile 2 - Number:
Home/personal email id 1: sarojnayak86@gmail.com
Home/personal email id 2: saroj_nayak_86@yahoo.co.in
Organization name:
Designation:
Department:
Managerial level:
In campus location:
Work (campus) address - Line 1:
Work (campus) address - Line 2:
Work (campus) address - City:
Work (campus) address - State:

Page 1 of 3
KnoWerX Education (India) Private
Limited
Examination Registration Form (Version 2011.02)
P
Other:
s
Work (campus) address - Postal code: w
Work (campus) address - Country: m
to
Work (campus) phone 1 - Country: F
n
Work (campus) phone 1 - City/area code: c
<
Work (campus) phone 1 - Number: id
Work (campus) phone 2 - Country: y

Work (campus) phone 2 - City/area code:


Work (campus) phone 2 - Number:
Work (campus) phone - Extension:
Work phone direct - Country:
Work phone direct - City/area code:
Work phone direct - Number:
Work email id 1:
Work email id 2:
Work mobile - Country:
Work mobile - City/area code:
Work mobile - Number:
Organization's industry classification -
Major:
Organization's industry classification -
Minor:
Preferred mailing address: Home
Main (preferred) email id for
communication: sarojnayak86@gmail.com
Is your fee paid/will be reimbursed by
your employer?
Would you like to participate in
employement referral program?
Exam date: 12-Mar-11
Exam city: Mumbai
Preferred option, if location does not
open: Register me for the location given below
Alt 1: Pune
Alt 2: Nasik
Morning exam:
APICS CSCP Normal: Certified Supply Chain
Afternoon exam: Professional-Mem

Amount payable in Indian Rupees (Rs.): 121,070


Amount paid: 31770
Payment mode: 88 Electronic Fund Transfer
KnoWerX bank account paid into: Deposited directly in HDFC-01822320000422
EFT from HDFC a/c no : 03652470001590
Cheque/draft/EFT number: Reference No - 7684A1
Cheque/draft/EFT date: 20-Jan-11
IFSC of sending bank: HDFC0000365
Payable at:

Page 2 of 3
KnoWerX Education (India) Private
Limited
Examination Registration Form (Version 2011.02)
P
Signature (please enter your name or s
signature): w
Date of filling this form: 21-Jan-11 m
to
F
n
c
<
id
y

Page 3 of 3

You might also like