International Course on

Road Safety Audit, Biomechanics & Crashworthiness

and Road Construction Safety
01 - 14 December, 2020
Select
Module 1A
COURSE APPLICATION FORM Online In Person
Module 2B
Online In Person

RETURN BEFORE October 15, 2020 Module 3A In Person

Module 3B In Person
A. Personal Details

Title Prof. Dr. Mr. Mrs. Ms. Surname ________________________ First Name ___________________

Date of Birth _________________ Sex:(Male / Female) ________ Job Title ________________________

Institute / Organisation __________________________________________________________________

Address ______________________________________________________________________________

_____________________________________________________________________________________

City_____________________________ Post Code ______________ Country _____________________

Home Phone ___________________________ Office Phone _________________________________

Email _____________________________________________

B. Passport Details (International applicants only)

Passport No _________________ Place of Birth __________________ Nationality ________________

Date & Place of Issue ______________________________ Valid Upto __________________________
Father's Name ___________________________________ Date of last visit to India ________________

C. Professional involvement in transportation planning and safety promotion.

(attach separate sheet)

D. How do you expect this course to help you in your future activities?
(attach separate sheet)

E. Financial Arrangement
i) Fees will have to be paid in advance for attending the course.
ii) All travel and local costs are expected to be borne by the participants or the participating organizations.
iii) Limited financial aid is available. Please indicate the absolute minimum aid needed by you, stating why it is
required and if it is towards travel, hotel or registration fees.
iv) Preference will be given to those who do not need aid.

Financial Aid Request

1) Registration Fees _________
2) Hotel _________
3) Travel _________

I am enclosing Demand Draft no.........................Dated........................drawn on..............................................

For US$ / INR................. ( in favour of “ FITT, IIT Delhi”)

ESSENTIAL DOCUMENTS REQUIRED TO PROCESS APPLICATION:-

BRIEF BIO DATA COPY OF PASSPORT

Date________________________________Signature______________________
World Health Organization