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467] lsDVj&21] fjax jksM bfUnjkuxj] y[kuÅ&226016
Institute of Cooperative & Corporate Management, Research and Training,
467, Sector-21, Ring Road, Indira Nagar, Lucknow-226016
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,sxzhDyhfuDl ,s.M ,sxzhfcftusl lsVa lZ ;kstukUrxZr izf”k{k.k dh uohure QksVks
Training under Agri-Clinics and Agri-Business Centres Scheme fpidk,a
Pl. Paste a Recent
vkosnu izi= Passport Size
Photograph
Application Form

1- vH;FkhZZ dk uke% Name of the Candidate:


2. firk@ifr dk uke% Name of the Father / Spouse:
3- tUefrfFk% Date of Birth: (DD-MM-YYYY)
4- fyax % ¼iq0@e0½ Sex : (Male / Female)
5- Js.kh %¼lkekU;@vU;fiNM+k oxZ@vuqlfw pr tkfr@vuq%tu tkfr½ Category: (Gen / OBC / SC/ST)
6- vk/kkj dkMZ la[;k ¼Nk;kizfr layXu djs½a : Aadhaar Card No. (Pl. Attach a Photo Copy)
7- LFkkbZ irk% Permanent Address:
xzke o iapk;r Village and Panchayat:
Cykd rFkk@vFkok rglhy% Block / Tehsil: ftyk % District:
jkT;@State: fiudksM % Pin Code:
8- i=kpkj dk iw.kZ irk% Address for Correspondence:
,lVhMh lfgr nwjHkk’k la[;k@eksckby uEcj % Telephone No. with STD Code / Mobile No:
bZ esy / Email ID:
9- “kSf{kd ;ksX;rk % ¼d`0 vadi=ks@
a izek.ki=ksa dh izekf.kr izfr;kW layXu djsAa ½
Educational Qualifications: (Please Attach Attested Copies of the Mark Sheets / Certificates)
izkIrkad@iw.kkZad xzsM@
mRrh.kZ lhthih,
dzekad mRrh.kZ ijh{kk dk uke cksMZ@fo”ofo|ky; o’kZ fo’k; Marks
Js.kh
Sl.No. Name of Examination Board/University Year Subjects Obtained / Grade /
Division
Total Marks CGPA
10- fo”ks’kKrk % Area of Specialization:
uksV% d`0 fo”ks’kKrk ds ckjs esa Li’V djs& a ,sxhz dYpj] ,sxzh- bathfu;fjax] ,sxzh- ekdsfZ Vax] ,suhey gLcSaMªh] ck;ksVsDukWykWth] Msjh VsDukWykWth] fQ”kjht+] QwM
U;wVªh”ku] QwM VsDukWykWth] QkWjsLVªh] gkse lkbal] gkWVhZdYpj] ,sxzh- eSut s esVa ] ejhu ck;ksykWth] :jy lkbal] lhM VsDukWykWth] lsjhdYpj rFkk ,oa
d`f’k&lEcaf/kr fo’k;ksa esa dksbZ vU; fo”ks’kKrk

Note: Please mention clearly regarding your area of specialization such as Agriculture, Agri. Engineering, Agri.
Marketing, Animal Husbandry, Biotechnology, Dairy Technology, Fisheries, Food & Nutrition, Food Technology,
Forestry, Home Science, Horticulture, Agri. Management, Marine Biology, Rural Science, Seed Technology, Seri-culture
and any other Specialization with Agriculture and Allied Courses.

11- vuqHko % Experience:


d`f’k d`f’k ds vfrfjDr
12- Ikkfjokfjd i`’BHkwfe / Family Background:
(i). Agriculture (ii).Other than Agriculture:
13- ,xzh&fctusl esa #fp / Agri-Business Interest:
izf”k{k.k ds mijkUr izkjEHk fd;s tkus okys m|e dk
(i). Nature of enterprise being planned to set up after the training
m|e LFkkfir fd;s tkus dk laHkkfor LFkku
(ii). Likely Place of establishment of enterprise:
izlkj@foLrkj dk;Z esa vfHk#fp] mlls lEcaf/kr vuqHko rFkk Hkfo’; esa d`’kdksa dh lsok djus dh :ijs[kk
(iii). Aptitude for extension work with brief details of extension
work done and vision for future in serving farmers.

13. Bank Account Details linked with Aadhaar:


[kkrk la[;k : Account No:
cSad@”kk[kk dk uke % Name of the Bank & Branch:
vkbZ,Q,llh dksM % IFSC Code:

gLrk{kj : Signature:
fnukad / Date:

uke : Name:……………………………......………

Please send your application form at following address:

The Nodal Officer - AC&ABC (NTI)


Institute of Cooperative & Corporate Management, Research and Training,
467, Sector-21, Ring Road, Indira Nagar,
Lucknow-226016, Uttar Pradesh

Email: info@iccmrt.ac.in; acabc.iccmrt@gmail.com