9/30/13

::: Citibank Payment Gateway :::

(ITP Web Registration Acknowledgement Form)

Date:______________
TIN NO:

Name of Applicant
Date of Birth
Mode of Payment
Employer Name
Employee Number
Valid Up To Date

ACK NO. 113974711T

:Mr SANJAY RAMESHBHAI PANCHAL

:29-Nov-1984
:Payment by Online ( 337)
:Evolutionary Systems Private Limited
:AHM-098
:19/11/2013

Please affix your

latest Photograph

Signature
(Please sign in the centre of the box)

Note :
* To complete your registration please visit any Point of Service (POS) office. If you do not complete your
registration within 50 days of issuance of Acknowledgement Number, your data will be purged from the system.
* You need to take print-out of this form to the POS along-with ORIGINAL proof of Photo Identity [Voter's Id
card/Passport/Driving License/Bank Pass Book (with Photo)/College ID card (not more than 4 years old)/PAN
card/Employment Identity Card].
* I have read, understood and I agree to the terms and conditions available on NSR website
https:\\nationalskillsregistry.com relating to my joining and using NSR and I agree to the same.

ACKNOWLEDGEMENT SLIP(For the use of POS only)

TIN NO :

Ack No : 113974711T
POS ID :

Name of Applicant : Mr SANJAY RAMESHBHAI PANCHAL

1. Received the Application form for Registration as ITP in the National Skills Registry and payment
made by ITP for Registration is Payment through Online.
Date:___________
(POS Seal and Signature)
Print

https://nationalskillsregistry.com/nasscom/pg/OnlinePayment

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