GUWAHATI BIOTECH PARK

GUWAHATI BIOTECH PARK INCUBATION CENTER

(An initiative of the  Govt. of Assam, Department of Biotechnology, Govt. of India and  IIT Guwahati )

Registration Form for Internship Program 

1.	Name (in block letters)  :  _______________________________________________ 

2.	Institution		:   ______________________________________________

3.	Qualification		:   ______________________________________________

4.	Area of Interest :                         Basic techniques in Molecular Biology, Microbiology and  Imaging
(Kindly choose any one)                 Biomolecule Profiling / Herbal Extraction         
                                          Application of Sophisticated Analytical Instruments
Others (Please specify) 	: ______________________________________________________________________                           
5.	Duration of internship required :          	  2 weeks               1 month                  45 days                      2 months
                                                                      3 months              4 months                 5 months                  6 months                         
6.	Sponsored By   	            : ________________________________________________________________
7.	Joining date (tentative)	            : ________________________________________________________________
8.	Personal details: 
(i)	Father’s/Mother’s/Guardian’s Name & Contact No : _________________________________________

(ii) Applicants Mobile No. :  _____________________   Email ID: _______________________________

(iii) Permanent Address : _________________________________________________________________

(iv) Address for communication : ___________________________________________________________

I hereby declare that the information provided above is true to the best of my knowledge.

(Signature of the applicant with date)

For Office Use Only

Registration Form No: 
Date:

Fee:

(By Cash/ Demand Draft): DD No.:________________Dated: _______________Bank: __________________

Finance & Accounts		Signature of Supervisor

Address: Guwahati Biotech Park, Technology Complex, IIT Guwahati, Guwahati-781039

Tel: +91-361-2690228; Email:  project@guwahatibiotechpark.com 
Website:  www.guwahatibiotechpark.com

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9.	 General Information & Instructions for the Intern: 

•	The Registration/Course fees are Non refundable. The fees should be sent by Cash/Cheque/DD in favor of “Guwahati Biotech Park Incubation Centre” payable at Guwahati. The amount may be transferred to the following bank details: A/C Name: Guwahati Biotech Park Incubation Centre, Bank: State Bank of India, Branch: ICD Amingaon, A/C No: 32537251968, IFSC Code: SBIN0009201

•	Students should submit two passport size photographs, a certificate from the host Institute / ID Card  along with the Registration Form. 
•	Students have to bear their own boarding/lodging /conveyance charges etc. 

•	The intern will be allowed to use the Laboratory Space any other facilities available at GBP as required in his/her area of interest. 

•	The intern has to maintain Log Book, Issue Registrar against the use of equipments. 

•	The intern will be issued glassware/plasticware/apparatus etc from GBP through the supervisor and must be returned in same condition on completion of the internship. In case of breakage or damage, the cost of the same shall be borne by the intern. 

•	The intern has to take prior approval of the supervisor and the competent authority for using any other facilities if required during the internship period. 

•	Filled   in   application   form   should   be   super   scribed   with   “Application   for   the Internship/Project/Dissertation opportunity at GBP” and send to Guwahati Biotech Park, Technology Complex, IIT Guwahati, Guwahati-781039

Declaration

I hereby declare that I will obey all the above Information and Instructions as prescribed by my supervisor and will also follow the general office decorum of GBP during my internship period.

(Signature of the applicant with date)

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