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Summer Research 2015 – Registration Form
Summer Research 2015 – Registration Form
Gather address info
If you are human, leave this field blank.
Please fill the form carefully, the information you enter here will be used through out the internship program.
Personal Details
Greeting
*
Mr.
Ms.
Given Name
*
First Name
Middle Name
Middle Name
Family Name
*
Last Name
Email
*
Please use same email address through out this internship, you would be filling several online forms through out this period. This should be your personal email, not institute provided email address
Phone Number
*
Must be the quickest number to reach you at (mobile)
Rakshak Intern ID
*
Alternate Phone number
Your College / Institute of Study
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IIT Kanpur
IIT Delhi
IIT Bombay
IIT Madras
IIT Kharagpur
IIT Roorkee
IIT Guwahati
IIT Gandhinagar
IIT Hyderabad
IIT Indore
IIT Jodhpur
IIT Patna
IIT Ropar
IIT Jodhpur
IIT Mandi
IIT BHU
IIIT Delhi
IIIT Allahabad
IIM Ahmedabad
IIM Bangalore
IIM Calcutta
IIM Indore
IIM Kozikode
IIM Lucknow
IIM Shillong
IIM Tiruchirappalli
IIM Ranchi
IIM Raipur
IIM Udaipur
IIM Raipur
IIM Udaipur
IIM Rohtak
IIM Kashipur
NIT Jamshedpur
SIBM, Pune
Xaviers Management, Bhuvneshwar
IFMR, Chennai
BITS Pilani
Madras School of Economics
Delhi School of Economics
Symbiosis Law
Campus Law Centre
Hindu College
Shri Ram College of Commerce, Delhi
Lady Sri Ram College for Women, Delhi
St. Stephen's College, Delhi
Hansraj College, Delhi
NLU, Bhopal
Other
Institute Name
Permanent Address ( your home town)
*
Please enter address of your hometown
Address Line 2
City and State
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Zip Code
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Emergency Contact Name, Address and Phone Number
*
Please list the contact details of at least 2 people 1. Full Name: Your Relation to the Person: Contact Number: Contact Address: 2. Full Name: Your Relation to the Person: Contact Number: Contact Address:
Any specific Medical Conditions we should know about?
Any allergies, medical condition that we should know about?
Bank Detials for Stipend and Expense Reimbursement
*
Your Name (as entered in Bank records): Bank Name: Account Number: Nature of account : Savings / Checking / Current Branch (Name and Address): Branch Code: Routing Number: IFSC Code:
Coming From (City)
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Date of Arrival for Summer Research ( Start Date)
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Approximate Time of Arrival to the city of research
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Leaving to (City going to at the finish of the Internship)
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Specific Interests, hobbies
*
Please list out your Specific Interests, hobbies and extracurricular activities you have been involved with. This information is used for group activities.
Future aspirations (Specific)
*
Where you want to see yourself 3-5 yrs after graduation. (Be brief)
Comments (if Any)
*
Any information you would like to share with us specifically