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

APPLICATION FORM

PART- I

3 x 4 cm

Nationality:                                                        Name of Course:                                                                  Institute :                    Commencing : From                              to                           DD/MM/YYYY                 DD/MM/YYYY
1. Personal Particulars
Name(s): Surname: Sex (tick one): Marital Status: Date of Birth: Passport No.:-
	MALE / FEMALE
	Date   -   Month   -  Year                           Date & Place of issue :-                                           Valid till :-
Address:	Office		Res.
Tel Nos.
Mobile/Cell :
Fax :
E-mail :
Special dietary needs, if any :

Person(s) to be notified in case of Emergency

	Official Contact	Personal / Family Contact
Name : Address: Tel Nos: Mobile /Cell : Fax: E-mail:

Educational Qualification/(s)

Degree / Diploma / Certificates	Year	Name of Educational Institute
1 2 3 4

Professional Qualification(s), if any:

Professional Qualification (s)	Year	Name of Institute
1 2 3 4

2.   Details of Employment/Profession (current & previous)

Name of Employer / Department / Company		Position	Period	Description of Work
Are you an employee of: (Mark appropriate box)
a. Government     □           b. Semi-government/Parastatal □ c. Private company □         d. Self-employed  □            e. Others  □
Details of present e Name / address : Tel. No. : E-mail :	mployer :

3.  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	Course Details & Duration	Year	Sponsor/Programme

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	Basic	Remarks
Spoken
Written
Mother tongue / Native language:                                            / Other language(s), if any :                                     English Language test administered by:                                                                                                      Tel. Number :                                          Name & Address :                                                                                 E-mail :                                                                                             Signature with date :

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 ?
2. Is the person examined physically and mentally able to carry out intensive training away from home?
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).
4. Does the person examined has any medical condition or defect which might require treatment during the course ?
5. List of any observed abnormalities indicated in the chest X ray.

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.