APPLICATION FORM FOR EMPANELMENT OF INDIVIDUAL TRAINERS

APPLICATION FORM FOR EMPANELMENT OF INDIVIDUAL TRAINERS
01 Name of the Applicant (BLOCK LETTERS) *
02 Father’/ Mother’ name *
03 Residential Address *
04 Village / Town *
05 Block/ Municipality *
06 Sub Division *
07 Phone No. *
08 Mobile No. * Update
09 Email ID*
10 Profile Photo*
11 PAN No. *

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12 Adhaar No. *
13 Educational Qualification * (Attach Copy in Highest Qualification)
14 Occupation *
15 Qualification For High Skill Traders / Services
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16 Qualification for Other Traders / Services (If any)
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17 Select Districts & Trades applying for empanelment
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18 Experience of providing Training in Trade / Service Applying for (Please provide Brief Description of Activities and Experience in the similar field including year of commencement. Use separate sheet if necessary)
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19 Award Received (If any) (Annexure-d)(optional)
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20 Whether any Special / Innovative Project or Capacity Building Programme taken up by the applicant (Give Details) (Annexure-d)(optional)
21 Photo documentation (optional) (Attach in Annexure-e)
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22 Any other related Information (optional)
I hereby declare that the information furnished above is true to my knowledge.
 
Declaration
1. I hereby declare that I have the capacity to arrange for / providing Machineries, Equipments and Training Materials required for organising the training programmes as Standardised by ICMARD for the traders / services I applied for.
2. I am able to serve as Trainer for both short and long term Programmes in the Urban and Rural Areas in nearby Districts of West Bengal as selected by ICMARD along with all types of Machineries, Equipments and Training Material support as and when required.
3. I am capable of providing Marketing and Network building Support and temporarily for the Target groups of Trainees for the Traders / Services under supervision of ICMARD.

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