PART-I

PROFORMA FOR FINANCIAL ASSISTANCE FOR ATTENDING INTERNATIONAL CONFERENCE/WORKSHOP ABROAD

fons'kksa esa vk;ksftr varjkZ"Vªh; lEesyu@dk;Z’kkyk esa Hkkx ysus ds fy, foÙkh; lgk;rk ds fy, izksQkekZ

RECORD SHEET

fjdkWMZ 'khV

1.  Name and Address ______

uke vkSj irk

Telephone No & Mobile No.

VsyhQksu ua o eksckby uacj ______

Email:

bZesy ______

2.  Designation
inuke ______
3.  Age/Sex/ D.O.B
tUe frfFk] mez vkSj fyax ______
4.  Name of the Conference/Seminar/Workshop
lEesyu@laxks"Bh@dk;’Zkkyk dk uke ______
5.  Place and Date
LFkku vkSj frfFk ______
6.  Whether applicant is reading/presenting a
Paper/chairing a session etc.
D;k vkosnd fjlZp isij i< jgk gS@
is’k dj jgk gS@l= dh v/;{krk dj jgk gSA ______
7.  Amount requested from D.S.T. Haryana
foKku ,ao izkS|ksfxdh foHkkx ls jkf’k dk vuqjks/k ______
8.  Details of international Conference attended in
the last three years, (Title of Conference dates,
country, funding assistance if any) ______
fiNsy rhu o"kZ esa varjkZ"Vªh; lEesyu es fy, Hkkx dk fooj.k
¼lEesyu dk 'kh"kZd]fnukd] ns’k] foRrh; iks"k.k lgk;rk vxj dksbZ gS½
9.  Signature of Applicant
vkosnd ds gLrk{kj ______
PART-II ¼Hkkx&2½
APPLICATION FORM FOR APPLICANTS
vkosndkssa ds fy, vkosnu i=
1.  Name (Surname First in Capital letters) ______
uke ¼cMs v{kjska esa miuke izFke½
2.  Designation ______
inuke
3.  Institution Name ______
laLFkk dk uke
Address ______
Ikrk
Phone ______
Qksu
Pin code ______
fiu dksM
4.  Date of Birth ______
tUe frfFk
Sex (fyax) ______Age (mez) ______
5.  Particulars of Conference ______
lEesyu dk fooj.k
a)  Title ______
'kh"kZd
b)  Venue (Place & Country) ______
LFkku ¼txg ,oa ns’k½
c)  Duration From ______To ______
vof/k
a)  Country Code ______
ns’k dk fiu dksM
6.  Broad Area of the Conference
LkEesyu ds O;kid {ks= ______
7.  Reason for Participation
Hkkx ysus dk dkj.k ______
i) Acceptance of Paper
isij dh Lohd`fr ______
ii) Chairing & Session
l= dh v/;{krk ______
iii) Invited Speaker
vkeaf=r oDrk ______
iv) Any other reason
dksbZ vU; dkj.k ______
8.  Particulars of financial assistance/hospitality Source (lzksr) ______
etc. the applicant has received from parent/host
or any other organisations/installations Amount(jde) ______
vkosnd dks Loa; dh laLFkk@estcku ls izkIRk@;k
fdlh vU; laxBu@izfr’Bkuksa ls izkIr foÙkh; lgk;rk@vkfrF; dk fooj.k
9  Have you received travel grant from the Department
of Science & Technology, Haryana in the last three
years, if yes, details thereof ______
D;k foKku vkSj izkSn~;ksfxdh foHkkx gfj;k.kk dh vksj ls fiNys rhu o"kZ esa ;k=k vuqnku izkIr gqvk gSA
;fn gk+W] rks rRlaca/kh C;kSj ns
10  Please give details of financial assistance if you have applied to:
;fn vki us foÙkh; lgk;rk ds fy, dgh vkosnu fd;k gS rks C;kSjk ns______
i) Ministry of Human Resources Development ______
ekuo lalk/ku fodkl ea=ky;
ii) Ministry of S&T G.O.I. foHkkx ______
foKku ,ao izkS|ksfxdh ea=ky; Hkkjr ljdkj
iii) Other Govt. Deptt./Ministry or
State Govt/ Agency ______
vU; ljdkjh foHkkx@ea=ky; ;k jkT; ljdkj@,taslh
11  Name of the Bank ______
cSad dk uke
Branch/City ______
'kk[kk@’kgj
Bank A/c no. ______
cSad [kkrk la[;k
IFSC code: - ______
vkbZ,Q,llh dksM
MICR code: - ______
,e vkbZ lh vkj dksM
12  Proposed date to leave India for the conference
and the likely date of return to India. ______
lEesyu es Hkkx ysus ds fy, Hkkjr NksMus dh izLrkfor frfFk
vkSj Hkkjr esa okilh dh laHkkfor rkjh[kA
13  Other Countries likely to be visited apart from the place of conference
lEesyu dh txg ls vyx vU; ns’kksa esa nkSjk djus dks lEHkkouk
Duration
vof/k ______
Purpose
mn~ns’; ______
14  Any other information which you may like to
furnish in support of your application ______
vius vkosnu ds leFkZu esa dksbZ vU;
tkudkjh izLrqr djuk pkgrs gSA
15  Benefits arising to the state on account of attending the conference.
lEesyu esa Hkkx ysus ls jkT; dks gksus okys ykHkksa dks foOkj.kA______
Recommendation of Head of Institute/
Department ______
laLFkku@foHkkx ds izeq[k dh flQkfj’k lhy ds LkkFk
Signature of the Applicant
vkosnd ds gLrk{kj