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APPLICATION FORM FOR EMPANELMENT OF ORGANISATION

APPLICATION FORM FOR EMPANELMENT OF ORGANISATION
01 Name of the Organisation (BLOCK LETTERS) *
02 Brief Portfolio of the Organisation * (within 50 KB) Upload .pdf
03 Registration No *
04 Registration Date *
05 Please Attach Copy * (within 50 KB) Upload .pdf
06 Official Address *
07 State *
08 District *
09 Block/ Municipality *
10 Sub Division
11 Police Station
12 Gram Panchayat
13 Village / Town
14 Post Office
15 PIN Code *
16 Phone No / Contact No. *
17 Name of the Organisation Head *
18 Photograph of the Organisation Head * (within 50 KB) Upload Only jpg, png
19 Mobile No. of the Organisation Head *
20 Email ID *
21 PAN No. of the Organisation Head * (within 50 KB) Upload Only Pdf
22 GSTIN of the Organisation (OPTIONAL) (within 50 KB) Upload Only Pdf
23 Date of Incorporation * (within 50 KB) Upload Only Pdf
24 Affiliation/ Accreditation/ Recognition of competent authority (If Any) (within 50 KB) Upload Only Pdf
25 Details of the Available Infrastructure (if any) (Location, Training Facilities, Equipments, Establishment etc.) * (within 50 KB) Upload Only Pdf
26 District/s and Trade/s applying for empanelment *
+ ADD
27 Transaction Number
28 Transaction Date
29 Transaction Proof
30 Whether the Applicant has at least Two Years experience of providing Training/ Capacity Building *
31 If Yes Please Provide - 1. Brief Description of Training/ Capacity Building Programmes undertaken in last Two Years along with supporting documents. 2. Work Order/ Letter from the Programme Coordinator. 3. Programme Completion Certificate (if any). (Download the format fill, scan and upload) (within 50 KB) Upload Only Pdf
32 Whether the applicant has prior experience of working with Govt. Departments/ Organisations/ Cooperative Banks/ Cooperative Societies/ NGOs (Give Details) *
33 If Yes Please Provide – 1. Brief Description of Training/ Capacity Building Programmes undertaken in last Two Years along with supporting documents. 2. Past and Present Empanelment as Vocational Skill Trainer (If Any) 3. Existing collaboration with recognised organisations (if any) 4. Work Order/ Letter from the organisations 5. Programme Completion Certificate (if any). (Download the format fill, scan and upload) (within 50 KB) Upload Only Pdf
34 Whether any Special/ Innovative Project or Capacity Building Programme taken up by the organisation (Give Details) (within 50 KB) Upload Only Pdf
35 Awards Received (If Any) (within 50 KB) Upload Only Pdf
36 Any other related Information (within 50 KB) Upload Only Pdf
37 Terms & Conditions
Declaration
1. We hereby declare that we have the capacity to arrange for/ providing Machineries, Equipments and Training Materials required for organising the training programmes as Standardised by ICMARD for the trades/ services we are applying for.
2. We are able to serve Trainersfor 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. We are capable of providing Marketing Support temporarily for the TargetGroups of Trainees for the Trades/ Services under supervision of ICMARD.