Indian Institute of Technology Kanpur

REGISTRATION FORM

Energy Conclave 2010

Workshop
On
“Civilian Nuclear Energy”
January 9, 2010
Name: _______________________________________________

Designation: __________________________________________ Paste Your

Recent
Organisation: __________________________________________ Photograph

Gender (for accommodation*): _M / F_

Correspondence Address: __________________________________________________

_________________________________________________ PIN:__________________

Phone: ____________________ Fax: ___________________E-mail:________________

Qualification:____________________ Experience:_______________________________

Category
□ Student □ Academic Institution
□ Industry / Regulatory Institutions / R&D Organisations

(Signature of Participant)
Note: Students should get the form countersigned from the head of the institution/
Department
Please send this form to
Divyadristi Prayogshala
Nuclear Engineering and technology Programme
Indian Institute of Technology Kanpur
Kanpur (UP) 208016 India

*Applicant has to pay the charges