NAME (print):_______________________________________GENDER: M/F         AGE:  _____ Yrs

DESIGNATION:_____________________________________________________

ORGANIZATION:____________________________________________________

_____________________________________________________________________

MAILING ADDRESS:__________________________________________________

______________________________________________________________________

_______________________________________________________________________

TELEPHONE:____________________

FAX:_____________________________

EMAIL:__________________________

QUALIFICATION (highest degree):_____________________________Discipline:_____________________

EXPERIENCE: _______ Yrs

BROAD AREA OF WORK/RESEARCH EXPERIENCE:___________________________________________

Do you have basic familiarity with
(a)Mathematics:  Yes/No
(b)Computer Programming: Yes/No
(c)Numerical Computing: Yes/No
(d)Internet/Web Browsing: Yes/No

COURSE FEE PAYMENT: DD No______________ Dt:_________________Rs:__________________

(Academic/Research Institution Certificate Attached: Yes/No)
[DD in name of "The Registrar, IIT Bombat (CEP A/C)]

 IIT Guest House accomodation Required:  Yes/No
(*Guest House Bill to be directly paid by participant)
 
 
 
 

Signature of Applicant:_____________________________________ Date:__________________________