IC ANNEXURE I

ANNEXURE I

Application Form for Visit of Scholars under Cultural Exchange Programme

Full Name(As per Passport):

Sex:

SC/ST/OBC:

Date of Birth:

Place of Birth:

Nationality:

Passport No.:

Place of Issue:

Valid Up to:

Present Designation:

Since When?

Institutional Address:

Tel:

Fax:

E-mail:

Degrees Obtained (Please indicate above P.G. Level):

Degree	Department/Discipline	University	Year
1. P.G.
2. M.Phil.
3. Ph.D.

Last Two Postings (Please indicate Organization/Institute/Designation/Period):

Designation	Organization	From	To

Publications, If Any (Please attach a separate sheet):

Country to be visited for the present Research Work:

	Language	Good	Average	Nil
Knowledge of Spoken Language of the Country Proposed to be Visited

Detail of previous Visits, If Any (Please specify year, purpose & sponsoring organizations):

Year	Purpose	Sponsoring Organization

Topic of your research for which the visit is required (Please enclose four copies of proposal of about 3000 words in A-4 size paper):

Funding Organization(s) for this Research:

Output of this Research (Please specify whether to write a report or a book):

Report	Book	Any Other (Specify):

Tentative Date of Completion of the Proposed Work:

Suggestions for Organizing Your Programme (Please attach a separate sheet giving, in order of priority, the names of the persons you would like to meet and organizations with address & telephone numbers if possible you would like to visit):

Contacts Already Made(Please attach copies of correspondence already exchanged with persons/institutions in connection with the organization of your proposed visit):

Have you received any Assistance from UGC/ICHR/ICPR for this Proposal to Visit?

(Specify Organizations):	UGC	ICHR	ICPR	Any Other(Please Specify)



When:

Have you received any Financial Assistance from ICSSR under any Programme to visit abroad (Specify, Programme, Country Visited, Year, Status of Final Report)?

Programmes	Country Visited	Year	Status of Final Report
CEP
Data Collection
Conference
Research Project
Fellowship

Place

Date

SIGNATURE

Enclosure(s):