Indian Institute of Technology Kanpur

REGISTRATION FORM

Energy Conclave 2010
Workshop
On
“Civilian Nuclear Energy”
January 9, 2010

Name: _______________________________________________
Designation: __________________________________________
Organisation: __________________________________________

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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

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