Insa-visiting Fellowship (Last date : 31/01/2017)

APPLICATION FORM FOR INSA - VISITING FELLOWSHIP

Proposed Laboratory / Research Institution to be visited in India

Name of Division with full address)

Subject

Duration of Visit

Area of Specialization

Proposed Date of Visit

1

(a) Name of Applicant

(b) Present position and contact address with telephone, E-mail and Fax

(c) Age & Date of Birth

2

Educational Qualification (From Post-graduation onwards)

Degree Obtained

Year

University / Institute

any other details / Remarks

3

Bio-data including research experience/interests and publications

(a)

Purpose of proposed visit:

Learning Specific Techniques

Collaborative Research

Any other Purpose

(b)

Details of the specific technique/utilizing collaborative research facilities in laboratory to be visited.

(c)

Whether the above facility is available in your parent organisation or not.

Yes/No

4(a)

Name of the Scientist(s) with whom work is proposed to be carried out.

(b)

Have you been accepted or have you obtained concurrence from the host institution. (Letter of acceptance to be enclosed)

5

Have your deputation with salary leave, etc. from your parent organisation for your proposed visit has been approved? (Please attach a deputation letter from your employer)

6

Name and address of two referees:

(i)

(ii)

7

Any other relevant facts which have not been covered in the above columns.

I certify that I have not availed INSA visiting scientist programme in last one year. Date: Place: Signature of the Applicant

Forwarded Seal: Signature & Designation of the Date Head of Institution