INDIAN COUNCIL FOR CULTURAL RELATIONS

AZAD BHAVAN. I.P. ESTATE , NEW DELHI - 11OOO2.

APPLICATION FORM
(To be submitted bv T2rNovember 2021)

Note: lt is compulsorv to fill uo all columns neatlv in Capital Letters with Postal address as
well as Tele./Mob. and E-Mail address.
'1 Name in F ull
(Surname) (Other name in full)

2 File No. with Scholarship Scheme

3 Sex _ (Male/Female)

4 Postal Address (with pin no.)

5. E-Mail Tel./Mob.

6. Nationality Date of Birth Passport No

Date & Place of issue _ Date of first arrival in lndia to take up

present course of study Year of
Study

7. Name of the University/lnstitute

8. Scholarship Holder/Self-rinancing, lf scholarship holder please state the scheme of

scholarship.

9 Iwish to join :
a. First Choice (Sl. No. ) b. Second Choice (Sl. No. ) mention serial number of
the camp in the bracket

Delhi/Bikaner/Jaisalmer/Jodhpur/Udaipur/Ajmer/Jaipur/Delhi
1
(from 22'd to 3oth December, 2021)
Delhi/Bikaner/Jaisalmer/Jodhpur/Udaipur/Ajmer/Jaipur/Delhi
2
(from 24rh December, 2021 lo 1* January,2022)
Delhi/Bikaner/Jaisalmer/Jodhpur/Udaipur/Ajmer/Jaipur/Delhi
3
(from 26rh December, 2021 lo 3'd January, 2022)
Delhi/Bikaner/Jaisalmer/Jodhpur/Udaipur/Ajmer/JaipuriDelhi
4
(from 28th December, 202'l to srh January,2022)
Gwalior/ Shivpuri/ Orchha/ Khajuraho/ Panna National ParU Jabalpur/
5 Bhedg haU Sanchi/ Bhimbetika/ Bhopal
(from 2 61h December, 2021 lo 2^d January,2022)
Gwalior/ Shivpuri/ Orchha/ Khajuraho/ Panna National ParU Jabalpur/
6 BhedghaV Sanchi/ Bhimbetika/ Bhopal
(from16'" December. 2021 lo 2'd January.2022)
Bhopal/ Bhimbetika/ Sanchi/ Jabalpur/ Bhedghav Kha.iuraho/ Panna Naitional
7 ParU Orchhai Shivpuri/ Gwalior
lfrom 26rh December. 2021 lo 2^d Janu?1y.2024
 Bhopal/ Bhimbetika/ Sanchi/ Jabalpur/ BhedghaU Khajurahoi Panna Naitional
8 ParU Orchha/ Shivpuri/ Gwalior
from 26th December, 2021 lo 2'd Janu 2022
Bangalore/Chennai/Mahabalipuram/Pondicherry/Bangalore
9
(from 25'' December, 2021 lo 2^d January,2022)
Bangalore/Chennai/Mahabalipuram/PondicherryiBangalore
10
(from 25'" December, 2021 lo 2^d January.zoz2)
Mumbai/Pune/Aurangabad/Mumbai
11
(from 26rh December, 2021 lo 2'd January, 2022)
Mumbai/Pune/Aurangabad/Mumbai
12
(from 26rh December. 2021 lo 2"d January,2022)
Mumbai/Goa
13
(from 22"d to 30rh December,202'l)
Mumbai/Goa
14
(from 25'h December, 2021 lo 2nd January,2022)
Mumbai/Goa
15
(from 28rh December, 2021 lo Sth January,2O22l
Mumbai/Goa
16
(from 31"r December, 2021 lo 8th January, 2022)
Cochin/ Munnar/Tekkady/Alleppey/Kanyakumari/Thiruvananthapuram
(from 28'h December, 2021 to 5rh January,2022)
'18 Cochin/Munnar/Tekkady/Alleppey/Kanyakumari/Thiruvananthapuram
(from 30'" December, 2021 lo 7th January,2022\
Thiruvananthapuram/Kanyakumari/Alleppey/Tekkady/Munnar/Cochin
19
(from 28'n December,2021 to 5'h January 2022)
Thiruvananthapuram/KanyakumariiAlleppey/Tekkady/Munnar/Cochin
20
(from 30'n December, 2021 lo 7th January 2022)

10. Have you ever attended any Camp organized by ICCR earlier (yes/No).

11 lf yes, place visited year and duration

from to

12. (a) I am sending herewith the Winter Camp fee of Rs.3.000/- bv Bank Draft, Bank
Name, No Dated for
Rs. 3,0001 payable in favour of Director General, ICCR. New Delhi (for ICCR
scholars)

(b) I am sending herewith the Winter Camp fee of Rs.10.000/- bv Bank Draft, Bank
Name, No.
Dated for Rs.10,0001 payable in favour of
Director General ICCR, New Delhi (for self financing scholars).

13 ln case of any expenses during the camp on medical/hospitalization, the same will be
borne by me (ICCR scholars as well as self financing students).

14 I hereby confirm that all the information provided by me in this form is correct.

15 I undertake to maintain discipline, follow all instructions given by the Camp Oflicer and not
take any action which will violate the discipline or order of the camp.

16. No A tiondrequest for C, of Camp will be enbrt, ained after 2?d November
2021 .
17. lf r fair to abide bv undertakino given by me in para 12,
13, above, r understand that the
camp officer can ask me to leiv-e theclmp ir.i"al[iv,
uli*,"t in such circumstances
will have to make my own arrangements for'in"
r"ttr. ji,li*v.
r

_, (Signature of the student)

Name of the student

This is to certify that Mr.iMiss/Mrs.

of is a bonafide student
. (Name of the tnstitute)

Signature with seal

Head of the lnstitution/tSA