Ministry of Science & Technology

Department of Science & Technology (DST)

INSPIRE

(INnovation in Science Pursuit for Inspired REsearch)

Internship Science Camp

January 5 9, 2016

organized by

ANDHRA UNIVERSITY

Visakhapatnam 530 003, Andhra Pradesh

REGISTRATION FORM

1.

Students Name

2.

E-mail

3.

Gender (Male / Female)

4.

Fathers Name

5.

% Marks/Grade in Class X Board Examination

6.

Class studying : Intermediate / XI / XII

7.

Name & Address of the College / School of

present study of the student

8.

Address of the student for correspondence

Affix Passport
size photo

Telephone Number :
Fax Number :
Mobile Number :
Signature of the student
Certified that the above facts are true, as per the College / School records and to our best information.
Signature of the Principal
Seal of the School / College
Note :

1.
2.

Enclose Xerox copy of X Class Marks Memo

Filled applications may be submitted to INSPIRE Office, Department of Organic Chemistry, Andhra University,
Visakhapatnam either in person or by post or email to inspireandhrauniversity@gmail.com or sidduchem@gmail.com