COFFEE BOARD

(Ministry of Commerce and Industry, Govt of India)

and

INDIAN INSTITUTE OF PLANTATION MANAGEMENT BENGALURU

(An Autonomous organization promoted by the Ministry of Commerce and Industry, GoI)

Jnana Bharathi Campus, Malathahalli Post, Bengaluru 560 056

E-mail : ;

CENTRE FOR INNOVATION AND ENTREPRENEURSHIP

(Sponsored by Coffee Board of India)

Reach-out Programme in Coffee Entrepreneurship

3 – 5July, 2016, Visakhapatnam

APPLICATION FORM

  1. Name: Ms. / Mr.

Pin
  1. Permanent

Address:

Pin
  1. Postal

Address

(current location)

-
  1. Tel. No: Mobile
  2. E-mail ID
  3. Educational Qualification (highest achieved, year):
  1. Age:8. Nationality:
  1. Current Occupation:
  1. Employment history (if any):
  1. Entrepreneurial experience (if any):
  1. Are you interested in starting a Coffee business? If yes, provide basic details:
  1. Have you previously attended any Entrepreneurship Development Programme? If yes, provide details.

Sl. No / Program title / Organizer / Program dates
  1. Are you a member of any industry association? If yes, provide details.
  1. Are you a Government employee? If yes, provide details of employer.
  1. Are you being sponsored to attend the programme? If yes, provide details of sponsor.

Sponsor name / Contact details (address, Ph No) / Relation with applicant
  1. Details of payment of participation fees:

Demand Draft(DD)NEFT / RTGS (tick any one)

If DD, details (DD. No, DD. Date, Drawn on (bank and branch), amount)

Place:

Date :Signature of the Applicant

Name:

The filled application may be scanned and e-mailed to . In addition, the hard copy of the application may be mailed (by post or courier) to the Coordinator, Centre for Innovation and Entrepreneurship, Indian Institute of Plantation Management, Malathahalli, Bengaluru – 560056, along with the participation fee (in case of DD). If RTGS / NEFT is used for payment of participation fees, the fees may be transferred to the indicated account (refer information brochure) after the e-mail of the filled application form is submitted. For clarifications, please contact or call 080-23218675 or 09448544902.