National Seminar on Educational Leadership VENU E: Centre for Educational Tec hnology, IIT K haragpur June 1st – 3rd , 2015 REGISTRATION FORM Name of the participant: ............................................................................................................................................................ Male Contact No (Mobile): .................................................................................. Female Email: ............................................................................................................................................................................ Professional You are a (tick any one) Faculty member Institute / College / Organization .................................................................................................................................... Accomodation Needed Yes Date of Arrival ...................................................... No Time of Arrival .................................................................. (Only Guest House accomodation will be provided by the Organisers , No TA/DA will be given to the Participants) Highest Qualification: ....................................................................................................................................................... Experience: ...................................................................................................................................................................... Demand draft details: (Please enclose DD drawn in favour of 'CEP STC, IIT Kharagpur' payable at State Bank of India (Br. Code: 0202) IIT Kharagpur) Bank name Place Branch code DD No: Address for correspondence: ................................................................................................................................... ............................................................................................................................................................................................................ ............................................................................................................................................................................................................ Date:............................. ................................................ Candidate Signature Place:…………………. .................................................. Head of the Organization (Signature with seal ) Note: Demand Draft shall be drawn in favour of 'CEP STC, IIT Kharagpur' payable at State Bank of India (Br. 0202) IIT Kharagpur Last date for Registration: May 20th,2015