Internship application form for voluntary organization1. Name of the Institution/Association/ NGO:2. Nature of the Institution (Society/ Trust/ Hospital /Others) and statute under which it is registered:3. Registered office, postal address with phone no (Land line and Mobile) email ID and website of the Institution:4. Year of establishment/registration:5. Number of years of operation:6. Name of the Nodal person and Designation:

Name:Designation:Mobile:Email id:

7. Numbers of activities of institution during the last 3 years. (Attached List):8. Operational area of Institution/ Association/NGO (District/ State/ Region etc.):9. Category of Institution/ Association/ NGO with respect to Jan Aushadi Scheme (Please tick mark):

1. Generic Medicine promotion amongmasses2. Generic Medicine promotion amongdoctors3. Promotion and communication4. Generic Medicine procurement and sale5. Generic Medicine free provision6. Others

10. Budget of the Institution for the last 3 years (in Rs.):

2011-122012-132013-14

11. PAN No:12. Duration of Internship(Please tick mark):

03 Days. / 05 Days. / 07 Days.

13. Period of Internship: Date From: To:14. Location of Internship: Vill:

P.O:City:P.S:District:State:PIN:

15. Travel (Round Trip)-(Please tick mark):(Travel Fare shall be paid in advance in the name of GK Dutta)

1. By Air. (Long Distance)2. By Train.3. By Bus.

16. Accommodation:(Please tick mark):

1. Hotel.2. Rent Room./PG3. Other (Please Mention details)

17. Fooding: Local Food.

DeclarationI/We hereby declare that all the information’s as mentioned above and true to the best of my knowledge.Place:Date:

(Signature of the Head of Institution/ Association/ NGO)

(Name, Designation & Seal)