Application Form for QIP Short Term course on

DESIGN: EDUCATION, RESEARCH & INNOVATION

(DERI)
2nd to 6th February, 2015, IIT Guwahati
1. Name (block letters)

2.

Designation & pay scale

3.

Organization

4.

Address for communication

Pin code:
Mobile :
E-mail :
5. Highest Academic Qualification :
6. Specialisation

7. Experience

:
(a) Teaching
(b) Industrial

8. Choice of Accommodation:
9. Category :

:
:

Hostel Will make my own arrangement.

General Reserved

Please register me for the course on Design: Education, Research & Innovation (DERI) to be
held at IIT Guwahati. I am sending an advance copy of this application by email to the
coordinator of the course. I undertake to send the Hard copy signed by the Head of our
Institution.
Place:
Date:

Signature of the applicant

SPONSORSHIP / NOMINATION CERTIFICATE

Prof/Dr./Mr./Ms./Mrs./......................................................................................................................
........................................................................................................................................................
.
is an employee of our institute and his/her application is hereby sponsored / nominated. The
applicant will be permitted to attend the short-term course Design: Education, Research &
Innovation (DERI) in Department of Design at IIT Guwahati during February 02 - 06, 2015, if
selected.

Date:

Signature of Authority

Designation:

Official Seal

--------------------------------------------------------For applicants from Industries and Government Department:

DD No
Date:
Bank:
Amount:

Signature of the Applicant

----------------------------------------------------------------------------------------------------------------The duly sponsored application form should be mailed to: (Charu Monga)
QIP Short Term Courses
Department of Design (DoD)
Indian Institute of Technology, Guwahati
North Guwahati, Guwahati-781 039, Assam
Ph. No. 0361-2582470(O), 0361-2582480(O), +91-8812870435
Fax No.: 0361-2690-2690762
E-mail.: qipedu2015@gmail.com