GUWAHATI BIOTECH PARK

GUWAHATI BIOTECH PARK INCUBATION CENTER

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

Enrollment Form

1.	Name (in block letters)		:  ________________________________________________________
2.	Institute Name & Address 	:  ________________________________________________________
3.	Area of Interest		: ________________________________________________________

4.	Project title			: ________________________________________________________

5.	Duration 			: ________________________________________________________

6.	To be supervised by		: ________________________________________________________

7.	Project/Internship/Dissertation 
     Cost				: ________________________________________________________

8.	Sponsored by			: ________________________________________________________

9.	Joining date			 : _______________________________________________________

10.	 Documents submitted		:  a.  _________________________________ 
 
  b.  _________________________________
  
 c. ____________________________
 
I hereby declare that the information provided above is true to the best of my knowledge.

(Signature of the student with date)

For Office Use Only

Ref. 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: +91-361-2690227/228/229; Fax: +91-361-2690227 Email:  project@guwahatibiotechpark.com Website:  www.guwahatibiotechpark.com