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Unisys Innovation Labs Application

Your Contact Information



First Name *



Last Name *



E-mail Address *



Job Title *



Primary Phone Number
*



Alternate Phone Number




Institution Information

Institution Name *



Institution URL *



Department Name *




Address Line 1 *



Address Line 2



City *



State/Province *



Postal Code *



Main Institution Phone
Number *




Key Institution Contacts

Program Coordinator
I will be the primary contact for UNISYS
First Name *



Last Name *



E-mail Address *



Title *



Phone Number *



Cell Number



Dean/Department Head
First Name *




Last Name *



E-mail Address *



Phone Number *



Faculty (Primary)
First Name *



Last Name *



E-mail Address *



Phone Number *



Faculty (Secondary)
First Name



Last Name



E-mail Address



Phone Number






List the Courses offered by your institute and annual enrollment of students against each course:



List the key IT related resources available at your institute






Briefly describe the key members of your faculty, their academic background, areas of research and
list key publications made by your students and faculty




Please mention number of students and faculty who will be participating in the UIL program











Date: Name and signature of authorized representative

Note: Please fill in all the details, sign and mail to UTFI@unisys.com scanned copy of the document
along with unsigned word document with all details