Institute of
Cheminformatics Studies
Participation Form
Paste your self attested photograph
For Office Use Only
No.                                                

NO COLUMN SHOULD BE LEFT BLANK (ALL IN BLOCK LETTERS)

Program applied for: Industry Program in Pharmaceutical Chemistry and Production

1. Name of the Participant _______________________________
2. Father's / Husband's Name _______________________________
3. Date of Birth (DD/MM/YYYY)
                                       
4. Address for Communication _______________________________
    _______________________________
  City _______________________________
  State ______________________________ Pin ____________________________
  Country ______________________________
5. Tel.: _______________________________ Mob: __________________________
6. E-mail: ____________________________ E-mail: ________________________
 
7. Work Experience(If Any):
 

Name of Organization

Designation

Total Work Experience
(In years)
     
     
     
     
     
8. Crossed Demand Draft No.____________dated__________Drawn on__________________ for Rs._____________
  (Bank draft must be drawn in favour of Institute of Cheminformatics Studies.Candidates are advised to write their name and address at the back of demand draft
 
10. Documents to be attached with application form:
 
(i) Total Fee Draft

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DECLARATION BY THE PARTICIPANT

I hereby declare that I have read and understood the conditions of eligibility and objectives of the program for which I seek participation and am eligible for the same. I uderstand that this is ICS's independent knowledge enhancement training program which is professional in nature and the enrollment in / completion of the program does not promise any employment or any specific eligibility to pursue higher studies. Disputes if any are subject to jurisdiction of Noida, District Gautam Buddha Nagar Courts only. I also understand that the fee is non refundable and nor shall the fee will be transferred or adjusted in any other program or service.



Date : _____________ (SIGNATURE OF THE PARTICIPANT)
Place : _____________

Downloaded Forms should accompany Demand draft of Rs. 250/- as application fee along with the program fee.

Send the Complete Application form at the Address Given Below :


Institute of Cheminformatics Studies
C-56A/28, Sector - 62
Noida - 201301, UP(INDIA)
Tel : 0120 - 4320801/02
Mob: 09810535368
E-mail: reply@cheminformaticscentre.org

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