APPLICATION FORM FOR EMPANELMENT OF INDIVIDUAL TRAINER

APPLICATION FORM FOR EMPANELMENT OF INDIVIDUAL TRAINERS
01 Name of the Applicant (BLOCK LETTERS) *
02 Father’s / Mother’s Name *
03 Residential Address *
04 Village / Town *
05 Block/ Municipality *
06 Sub Division *
07 Phone No.
08 Mobile No. * Update
09 Email ID*
10 Trainer Photograph (within 20 KB) Upload .jpg or .jpeg*
11 PAN No. * (within 80 KB) Upload .jpg or .jpeg

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12 Adhaar No.* (within 80 KB) Upload .jpg or .jpeg
13 Educational Qualification * (Attach Copy in Highest Qualification) (within 80 KB) Upload .jpg or .jpeg
14 Occupation * (within 80 KB) Upload .jpg or .jpeg
15 Qualification For High Skill Traders / Services (within 80 KB) Upload .jpg or .jpeg
+ ADD
16 Qualification for Other Traders / Services (If any) (within 80 KB) Upload .jpg or .jpeg
+ ADD
17 Select Districts & Trades applying for empanelment
+ ADD
18 Experience of providing Training in Trade / Service Applying for (Please provide Brief Description of Activities and Experience in the similar field including year of commencement. Use separate sheet if necessary)
+ ADD
19 Award Received (If any) (optional)
+ ADD
20 Whether any Special / Innovative Project or Capacity Building Programme taken up by the applicant (Give Details) (optional)
21 Photo documentation (optional) (Attach in )
+ ADD
22 Any other related Information (optional)
23 Terms & Conditions
I hereby declare that the information furnished above is true to my knowledge.
 
Declaration
1. I hereby declare that I have the capacity to arrange for / providing Machineries, Equipments and Training Materials required for organising the training programmes as Standardised by ICMARD for the traders / services I applied for.
2. I am able to serve as Trainer for both short and long term Programmes in the Urban and Rural Areas in nearby Districts of West Bengal as selected by ICMARD along with all types of Machineries, Equipments and Training Material support as and when required.
3. I am capable of providing Marketing and Network building Support and temporarily for the Target groups of Trainees for the Traders / Services under supervision of ICMARD.