Apu

APPLICATION FORM • If you are applying yourself, please fill all details and email the application to [email protected]. • If you are nominaing someone, provide as much information as possible – name and contact details necessary, at the very least. • By filling in your name at the bottom, you agree to abide by the Terms and Conditions of Lead India. Name : RAY_____________________________

__APURBA KUMAR

Date of Birth (DD/MM/YY) : 1979______________________________

_12-03-

Gender

:

__Male_____________________________

Highest Educational Qualification :B.Sc, Diploma in Civil Engg., MCA (Studing)_______________________ Occupation (Self-Employed/Salaried/Others) _____Salaried___________________

:

If self employed, describe nature of business : _____________________ _____________________________________________________________ How many people do you employ? (0/1 - 10/11 - 100/100+):___________ If salaried, designation:______Technical Assistant____ _______________________________ Company: ________Calcutta University____________________________________________ If others, provide details _________________________________________

Languages known:, Language 1: ____ Bengali Degree of Proficiency (Read/Write/Speak): ____( Read/Write/Speak )_________ ____________________________ Language 2: ___ English ___ ___________ Degree of Proficiency (Read/Write/Speak): _____(Read/Write/Speak _)___________________________ Language 3: _____ Hindi _ _____________ Degree of Proficiency (Read/Write/Speak): __(Read/ Speak)______________________________ Postal Address: _ 5/21, CHITTARANJAN COLONY___________________________________________ ______ _ _P.O.-JADAVPUR UNIVERSITY_____________________________________________________ ______________KOLKATA700032______________________________________________________ Email Address: [email protected]_____________________________________________ ___ Phone No.: __1>_9231906289__2>03324257936_______________________________________________ Which city are you applying from? (Please choose one of: Ahmedabad, Bangalore, Delhi, Hyderabad, Kolkata, Lucknow, Mumbai, Pune):__Kolkata___________________________ Have you ever held a position of leadership in your school/college/locality? If so, give details _________Class Captain in Schools____________________________________________________________ _________Cricket Captain in School____________________________________________________________ _________Organizing Tour/Picnic _in College_and in Office__________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

_____________________________________________________________________ *By filling out this form I agree to abide by the terms and conditions of the Lead India programme. (For details of terms and conditions, log on to www.lead.timesofindia.com)

(NAME) APURBA KUMAR RAY