APPLICATION FORM FOR EMPANELMENT OF INDIVIDUAL TRAINER

APPLICATION FORM FOR EMPANELMENT OF INDIVIDUAL TRAINER
01 Name of the Applicant *
02 Photo * Upload Photo (Only JPG max 50 KB)
03 Father’s / Mother’s Name *
04 Permanent Address * Upload Address Proof (Only PDF max 50 KB)
Address Line 1 *
Address Line 2
District * Block *
Municipality/ Panchayat * Village/ Town *
PIN Code *
05 Correspondence Address * Same as Registered Address
Address Line 1
Address Line 2
District * Block *
Municipality/ Panchayat * Village/ Town *
PIN Code *
06 Mobile No. *
07 Alternate Mobile No.
08 Email ID *
09 Date of Birth * Gender
Age:
10 PAN No. * Upload Copy (Only PDF max 50 KB)
11 Aadhaar No. * Upload Copy (Only PDF max 50 KB)
12 UDYAM Registration No. Upload Copy (Only PDF max 50 KB)
13 Artisan Card No. Upload Copy (Only PDF max 50 KB)
14 Brief Portfolio of the Candidate Within 300 Words
15 Highest Educational Qualification * Upload Copy (Only PDF max 50 KB)
16 Occupation *
17 Highest Professional Qualifications in the Trades Applied for [Max 20 Nos.]*
Select Trade Write Qualification Upload Diploma/ Certificate (Only PDF max 50 KB) ADD
18 Recognition/ Empanelment/ Affiliation
Upload Certificate (Only PDF max 50 KB) [Max 5 Nos.] ADD
19 Work Order / Completion Certificate of Training Programmes conducted under Govt. Organisations/ reputed Non-Govt. Organisations in last 3 years
Upload Certificate (Only PDF max 50 KB) [Max 3 Nos.] ADD
20 Awards / Accolades (If any) Within 300 Words
21 Photos of Training Programmes/ Awards Received
Upload Certificate (Only PDF max 50 KB) [Max 3 Nos.] ADD
22 Transaction Details * Upload Copy (Only PDF max 50 KB)
Transaction No.*
Date of Transaction*
Amount of Transaction*
From Bank*
23 Any other Related Information Within 200 Words
24 SELECT DISTRICTS AND TRADES APPLYING FOR EMPANELMENT *
 
ADD Select Trades (Maximum 20)
25 Date Place * Signature * Upload Copy (Only JPG max 50 KB)
Declaration (Individual Trainers)
I hereby declare that –
1. The information furnished above are true to best of my knowledge.
2. I would strictly abide by the Terms & Conditions stated in the “Expression of Interest” and deliver the services as required with optimum sincerity.
3. I have not been barred/ banned/ restricted from any such services from any Govt. or Non-Govt. Organisations in the past.
4. I have a clean legal background and no Criminal Case has been filed against me in the Court of Law as per my knowledge.
5. I am able to serve as a Training Provider for both short and long duration Programmes of the selected trades in the Urban and Rural Areas of the selected District/s of West Bengal along with all types of Machineries, Equipments and Training Material support as and when required.
6. I am capable of providing Marketing and Network building Support temporarily for the Target groups of Trainees.