Serial No.
GUWAHATI BIOTECH PARK INCUBATION CENTRE
Technology Complex: IIT Guwahati, Guwahati 781039
                              APPLICATION PROFORMA FOR EXPOSURE VISIT

Name of the Visiting Institute:

Address of Institute / Organization:

Department(s):

Total number of students:
(List to be attached)

Phone:                                                             Email:

Amount to be paid:

Signature of Co-ordinator/Faculty:	Signature of the forwarding authority

Name:	Name:
Designation:	Designation:

                                                     For Office Use Only

 Amount Received:
 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 Up to 10+2 standard	Graduate/
Post Graduate/Research Scholars	Others/Professionals
/industry professionals etc	
Free	Rs. 25/person	Rs. 100/person	

Charges (Cash / Check/Demand Draft):
(Cheque/DD should be drawn in favour of Guwahati Biotech Park Incubation Centre, payable at Guwahati)

F / A Section, GBP
Date & Time of receipt of Charge:	 Concerned Official, GBP

Address: Guwahati Biotech Park, Technology Complex, IIT Guwahati, Guwahati-781039 Tel: +91-361-2690227/228/229; Fax: +91-361-2690227 Email: info2gbp@guwahatibiotechpark.com

Website: www.guwahatibiotechpark.com