Tel. 0571- 2700920-23 (Ext.3634) Fax: 0571-2706252

Science Education Quality Improvement Programme 2009-10

REQUEST FOR PARTICIPATION

Course Applied for:……………………………………………………

 1.   Name (in Block Letters):                                                         

2.       2.   Date of Birth:                            3. Sex : M/F        4. Academic Qualifications:

5.       5.   Name & Address of the Institution:

       Vill./Mohalla:.............................      P.O.:.............................. Distt.:...............................

        State:............  Pin code:............................. Personal Phone No.:..............................

6.       6.   Experience of teaching  (Science/Mathematics) in years:................

        Class IX & X  ………………….. Class XI & XII………………… ….

 7.  Name of course, with date, attended, if any, at this Centre:...................................

8.   8.   Mention the specific topics / difficulties that you would like to be covered in the            course. (Attach a separate sheet if needed)

Signature of the teacher                                                                                              Date:

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Recommendation of the Principal / Competent Authority

I certify that the information given above is correct to the best of my knowledge and recommend  Mrs. / Ms. / Mr. / Dr................................................................................. for participation in the Course. If selected he/she will be granted leave for the entire duration of the Course.

 Name                                                       Signature                                Date                        Seal