VISHWA YUVAK KENDRA
(INTERNATIONAL YOUTH CENTRE) 

Jointly organized by

URI

Cosmic Community Centre - CC unit of United Religions Initiative,

Karickam P.O., Kottarakara, Kollam, Kerala.

Email urikarickam12@gmail.com 

Phone No. 0474 2663903

Training Program on

 “Community Based Disaster Preparedness for Risk Reduction”

3-5 August, 2017 at Thiruvalla

APPLICATION FORM

(PLEASE FILL UP THE PARTICULARS IN BLOCK LETTERS)

1.             Name of applicant in full:_____________________________________________________________________________

2.             Date of birth ____________Age:_____ Sex:    Male             Female                         T. Gender

3.             Educational Qualification:_________________________________________________________________________________

4.             Occupation (with designation):____________________________________________________________________________

5.             Name and address of the  organization/Institution: ______________________________________________________

               

____________________________________________________________________________________________________________

                               

                PIN ___________    Phone No: ________________E-mail: _______________________________________

7.             Years of experience:_____________________________________________________________________

               

8.             Reason for participating in this Training Programme: __________________________________________ ______________________________________________________________________________________

9.             Whether participated in any such training/workshop before:                  (Yes/No).  If yes, please give details __________________________________________________________________________

10.          Arrival: ___________  Departure:____________  Food habit: Vegetarian / Non Vegetarian (Pls. tick)

11.          Registration fee payment details: DD No/Cash.___________ Dated ______________Amount Rs._______

               

(Signature of the sponsoring organization)                                                      (Signature of the participant)

(If sponsored by an organization, please attach copy of the letter with the application)

Please note           1.             Only confirmed participants allowed to participate.

2.             Provisional registration may be sent before 30^th June 2017 through email urikarickam12@gmail.com / mathewlwsi@gmail.com