Icar Doc

ICAR Summer School TOOLS AND TECHNIQUES FOR PLANNING MONITORING, EVALUATION AND IMPACT ASSESSMENT OF EXTENSION PROGRAMMES (JULY 21-AUGUST 10, 2009) APPLICATION FORM

1. Full name in (Block letters): ……………………………………………………………… 2. Designation: ……………………………………………………………………………….. 3. Present employer and address: ………………………………………………………………………………………………. ………………………………………………………………………………………………. 4. Address to which reply should be sent(in block letters) ………………………………………………………………………………………………. ……………………………………………………………………………………………….

5. Permanent address ………………………………………………………………………………………………. Phone No…………………………….(M)…………………………………. Fax…………………………………..E-mail……………………………….. 6. Date of Birth 7. Sex M/F 8. Nature of work and experience ………………………………………………………………………………..................... 9. Mention about the training attended during last five years Sl. No.

Training

Duration (Days)

Year

10. Experience in Planning, Monitoring and Evaluation of extension programmes. 11. List your training needs. a. b. c. d. e. 12. Academic record Exam Subjects Passed (Main/ Subsidiary) Bachelor’s degree

Year of passing

Class/ ranks, distinctions etc.

Univ. Or Instt.

Master’s degree Other certificate Dip./degree Ph.D.

Date: Place:

Signature of applicant

13. Recommendations of the forwarding Organization: ……………………………………………………………….

Signature

Date:……………………

Designation

Certificate: It is certified that the above mentioned information has been checked and found correct.

Signature and designation of The Sponsoring Authority with Address