International Course on

Road Safety Audit, Biomechanics & Crashworthiness

and Road Construction Safety
01 – 14 December 2020

Select (√ )
COURSE APPLICATION FORM Module 1A
Online In Person
Module 2B
Online In Person
RETURN BEFORE October 15, 2020
Module 3A In Person
Module 3B In Person
A. Personal Details

Sur Name: [Click here and type surname] First Name: [Click here and type first name]

Title: [Click here and type Prof. Dr. Mr. Ms.] Date of Birth: [Click here and type date of birth]

Job Title: "[Click here and type Job Title]" Sex: [Click here and type male/female]

Institute / Organisation: [Click here and type Instt. / Org.]

Address: [Click here and type Address]

City: [Click here and type city] Pin Code: [Click here and type pin code]

Country: [Click here and type country] Office Phone: [Click here and type phone number]

Home Phone: [Click here and type phone] Email: [Click here and type email

B. Passport Details (International applicants only)

Passport No. : Place of Birth :

Nationality : Date & Place of Issue :

Valid upto : Mark of Identification :

Father’s Name : Date of last visit to India :

C. Professional involvement in transportation planning and safety promotion. (attach separate sheet if necessary)

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

1. Fees will have to be paid in advance for attending the course.

2. All travel and local costs are expected to be borne by the participants or the participating organizations.
3. 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.
4. Preference will be given to those who do not need aid:

Financial Aid Request

1) Registration Fees: [Click here and type Amt.]

2) Hotel: [Click here and type Amt.]

3) Travel: [Click here and type Amt.]

Registration Payments

I am enclosing Demand Draft no [Click here and type DD no.] Dated [Click here and type date.] drawn on [Click
here and type bank name.] For US$ / INR [Click here and type Amt.] ( in favour of “FITT, IIT Delhi”)

ESSENTIAL DOCUMENTS REQUIRED FOR PROCESING YOUR APPLICATION:

 BRIEF BIO DATA ● COPY OF PASSPORT

Date Signature

Correspondence address :
Please email / fax / post your application to:

Diya Walia / Peter Tennent

CONFER
TRIPP Course Secretariat
D -1, Kalindi Colony, New Delhi - 110065, India
Tel : +91 11 26919377, 26849399
E-mail : diya@confer.world; awconfer@gmail.com

 Page 2