GOVERNMENT OF INDIA MINISTRY OF EXTERNAL AFFAIRS
INDIAN TECHNICAL AND ECONOMIC COOPERATION ( ITEC ) AND SPECIAL COMMONWEALTH ASSISTANCE FOR AFRICA PROGRAMME ( SCAAP )
(Application for the courses fully funded by the Ministry of External Affairs, Government of India)
Please read instructions carefully before applying
Nationality: Name of Course: Institute
: Commencing :
From
to
DD/MM/YYYY DD/MM/YYYY
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1. Personal Particulars
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Name(s):
Surname:
Sex (tick one):
Marital Status: Date of Birth:
Passport
No.:-
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MALE / FEMALE
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Date -
Month
- Year
Date &
Place of issue :-
Valid till :-
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Address:
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Office
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Res.
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Tel
Nos.
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Mobile/Cell :
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Fax :
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E-mail :
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Special dietary
needs, if any :
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Person(s) to be notified in case of Emergency
Official Contact
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Personal / Family
Contact
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Name :
Address:
Tel
Nos: Mobile /Cell : Fax:
E-mail:
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Educational
Qualification/(s)
Degree / Diploma / Certificates
|
Year
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Name of Educational
Institute
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1
2
3
4
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Professional
Qualification(s), if any:
Professional Qualification (s)
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Year
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Name
of Institute
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1
2
3
4
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2.
Details of Employment/Profession (current &
previous)
Name
of Employer / Department
/ Company
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Position
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Period
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Description of Work
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Are you
an employee of: (Mark appropriate
box)
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a. Government □ b. Semi-government/Parastatal
□
c. Private company □ d. Self-employed
□ e. Others □
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Details of present
e
Name / address
:
Tel. No.
: E-mail :
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mployer :
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3. 
Have you ever attended a course sponsored by
the Government of India? (Mark one) YES NO
Have you ever attended a course sponsored by
the Government of India? (Mark one) YES NO(i) If answer to 3 is yes, details of the Course
4. Details of Course(s) attended, if any, outside your country:
Country
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Course Details & Duration
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Year
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Sponsor/Programme
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5. Please describe in your own words (about 100 words):
(a) qualification/experience in the related to the course applied for; &
(b) reason (s) for applying for this training course.
6. 
Certification of English language
proficiency (by Indian Mission/Designated Authority)
Good
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Basic
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Remarks
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Spoken
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Written
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Mother tongue
/ Native language: /
Other language(s), if any :
English Language test
administered by:
Tel.
Number :
Name &
Address :
E-mail :
Signature with date :
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MEDICAL REPORT
(To be certified
by
a doctor/hospital on the panel of the
Indian Mission, UN Mission, if any or
as designated by Indian Mission)
(i)
Name of
Applicant:
(ii)
Age:
(iii)
Sex: (Male
/ Female)
(iv)
ight (cm):
(v)
eight
(kg):
(vi) Blood
Group: (vii)Blood Pressure:
1.
Is
the person examined in good health at
present ?
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2.
Is
the person examined physically
and mentally
able to carry out intensive training away from home?
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3. Is the person free
of infectious diseases
(HIV/AIDS, tuberculosis, trachoma, skin diseases etc),
Yellow fever
certificate
(in case of people coming
from that region or as
laid out in WHO Regulations).
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4.
Does the person
examined has any medical condition
or
defect which might require
treatment during the course ?
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5.
List
of any observed abnormalities indicated
in the chest
X ray.
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I certify that the applicant is medically fit to undertake a training course in India.
Name of Doctor/Physician:
Registration No.:
Address
of Clinic / Hospital
and City / Town :
Telephone
:
E mail:
Date:
Signature of Doctor/Physician:
Seal of Clinic/Hospital:
IMPORTANT NOTICE
•
Please read the form carefully. The application will be automatically
rejected if any column is inaccurate, incomplete or blank.
•
Declaration by the candidate
and the recommendations from
employer,
if
any,
are
compulsory
pre-
requisites.
• Working knowledge of the English language is a pre-requisite. For English language and language related
courses, basic knowledge of English is required.
• Candidates who leave the course midway
for personal reasons without prior permission
of the Ministry of External Affairs or remain absent from the programme without sufficient reasons are expected to refund the cost
of training
and airfare to Government of
India.
• Female candidates are hereby advised that they should not travel to India to attend the course applied for
in case they are in family way.
UNDERTAKING BY THE APPLICANT
I,
(Name, Middle
name, Family name)
of (country)_ certify that information provided by me in this form is true,
complete and correct.
I also
certify that :-
(i)
I have read
the course brochure and that I am aware of the course contents and living conditions in India *.
(ii)
I have sufficient
knowledge of English to
participate in the training programme.
(iii)
I am medically fit to participate in the Course and have
submitted a medical certificate
from the designated doctor.
(iv)
I have not attended any programme previously sponsored by Government of India.
(v)
I have not applied for or am not required to attend any other training course/conference/meeting etc. during the period of the course
applied for.
If accepted for the ITEC / SCAAP training programme, I undertake to:
(a) Comply
with the instructions and abide
by
Rules, Regulations
and guidelines as may be stipulated by both the nominating
and sponsoring Governments in respect
of the training;
(b) Follow
the full and complete
course of study or training and abide by the Rules of the University/Institution/ Establishment in which I undertake
to study or undergo
training;
(c)
Submit periodic
assessments / tests conducted by the Institute (progress report which may be prescribed);
(d)
Refrain
from engaging in political activity,
or any form of employment
for profit or gain;
(e)
Return to
my home country at the end of the
course
of study or training;
(f) I
also fully undertake that if I am granted a training
award, it may be subsequently withdrawn
if I fail to make adequate progress or for other sufficient cause
determined by the host Government.
For lady participants :- I comfirm that I will
not travel to India to attend the Course
I have applied for if I am in the family way.
Date:
Place: (SIGNATURE OF THE APPLICANT)
Name:
* Details of the course are on the
website of the Institute or
can be obtained from them by e-mail.
