APPLICATION FORMAT FOR SEEKING INFORMATION UNDER RTI-2005 Sl. No.

1 2 3 Information to be provided by the information seeker Debraj Chakrabarti Indian 27B Hijli Co-operative Society, Near Prembazar Market. Kharagpur, Dist. Midnapore West Bengal. PIN-721306 03222-278034 debraj.chakrabarti@gmail.com TIFR Centre for applicable Mathematics, Sharadanagar, Chikkabommasandra, Post Bag No. 6503, GKVK Post Office, Bengaluru, PIN-560065 080-6695 3728 debraj.chakrabarti@gmail.com

Particulars Name Nationality / citizenship Permanent address

Phone : Email ID: 4 Address for correspondence

Phone : Email ID: Details of information required (If necessary a separate sheet may be attached)

Please find details attached sheet.

in

Details of application fee paid Demand Daft No. & date Amount Drawn in favour of

NOTE: Application fee Rs.10/- and information copy @ Rs.2/- per page, a Demand Draft drawn in favour of Indian Institute of Science, Bangalore-560012 is required to be sent to the Public Information Officer, Indian Institute of Science, Bangalore560012, Karnataka State. For more details visit website:www.iisc.ernet.in/rti

SIGNATURE OF THE APPLICATION