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<title>--6th Science Conclave --</title>
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<table width="595px" border="0" align="center" cellpadding="0" cellspacing="0">
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<td valign="top" > </td>
<td valign="top"><form name="userFrm" action="" method="post" onsubmit="return validateUserF(this);">
<table width="100%" border="0" align="center" cellpadding="0" cellspacing="0">
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<td valign="top" > </td>
<td valign="top"><table width="100%" cellpadding="2" cellspacing="2">
<tr align="center">
<td colspan="2" ><img src="newheader.png" width="840" height="138" alt="Header" /></td>
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<tr align="center">
<td colspan="2" ><table width="100%" border="0">
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<td><img src="scienceConclave.png" alt="Science Conclave" width="80" height="100" align="middle" /></td>
<td align="center" class="thickBorder"><p align="center"><strong> SIXTH SCIENCE CONCLAVE - 2013 </strong></p>
<p align="center"><strong> A Science Popularisation Programme</strong><strong></strong></p>
<p><span class="style6"><strong><em> (A Joint Initiative of MHRD & DST, Govt. of India, organized by IIIT-Allahabad: </em> December 08-14, 2013<em> ) </em></strong></span></p></td>
<td align="right"><img src="iiita.png" alt="IIITA Logo" width="80" height="100" /></td>
</tr>
</table></td>
</tr>
<tr align="center">
<td colspan="2" ><p class="style7"><u>REGISTRATION FORM </u> </p></td>
</tr>
<?php if($forrecordId){?>
<tr>
<td width="36%" align="left" bgcolor="#CCCCCC" > Registration Id</td>
<td width="64%" align="left" ><strong><?php echo $registrationId?></strong></td>
</tr>
<?php }?>
<tr align="center">
<td colspan="2" bgcolor="#CCCCCC" ><strong> <u>INFORMATION ABOUT THE COUNTRY </u></strong></td>
</tr>
<tr>
<td align="left" ><strong> Nomination from (NAME OF THE COUNTRY) </strong></td>
<td align="left" ><?php echo $userObj->getCountryName($countryId);?></td>
</tr><tr>
<td align="left" ><strong> Group Affiliation </strong></td>
<td align="left" ><?php if($groupAffiliation==0) {echo "ASEAN"; }else if($groupAffiliation==1){ echo "SAARC"; } else if($groupAffiliation==2) { echo "AFRICA"; } else { echo "OTHERS";}?></td>
</tr><tr>
<td colspan="2" align="left" ><strong> Address of the Secretariat / Corresponding Department </strong></td>
</tr><tr>
<td align="left" > Address</td>
<td align="left" ><?php echo $secAddress?></td>
</tr><tr>
<td align="left" > State / Territory </td>
<td align="left" ><?php echo $secState?></td>
</tr>
<tr>
<td colspan="2" align="left" ><table width="100%" border="0">
<tr>
<td width="36%"> Phone (With ISD Code) </td>
<td width="18%"><?php echo $secPhone?></td>
<td width="14%"> Mobile</td>
<td width="32%"><?php echo $secMobile?></td>
</tr>
</table></td>
</tr>
<tr>
<td align="left" > Email</td>
<td align="left" ><?php echo $secEmail?></td>
</tr><tr align="center">
<td colspan="2" bgcolor="#CCCCCC" align="center"><strong> <u>INFORMATION ABOUT THE INSTITUTE / UNIVERSITY </u></strong></td>
</tr>
<tr>
<td align="left" ><strong> Name of Institution</strong></td>
<td align="left" ><?php echo $nameOfUniver;?></td>
</tr>
<tr>
<td colspan="2" align="left" ><table width="100%" border="0">
<tr>
<td width="36%" align="left" ><strong> Head of Institution/HOD/Registrar </strong></td>
<td width="14%" align="left" ><?php echo $headOfInst;?></td>
<td width="14%"><strong>Designation</strong></td>
<td width="36%"><?php echo $headDesignation?> </td>
</tr>
</table></td>
</tr>
<tr>
<td colspan="2" align="left" ><strong> Address of the Institution </strong></td>
</tr><tr>
<td align="left" > Address</td>
<td align="left" ><?php echo $univerAddress?></td>
</tr><tr>
<td align="left" > State / Territory </td>
<td align="left" ><?php echo $univerState?></td>
</tr>
<tr>
<td colspan="2" align="left" ><table width="100%" border="0">
<tr>
<td width="36%"> Phone (With ISD Code) </td>
<td width="18%"><?php echo $univerPhone?></td>
<td width="14%"> Mobile</td>
<td width="32%"><?php echo $univerMobile?></td>
</tr>
</table></td>
</tr>
<tr>
<td align="left" > Country</td>
<td align="left" ><?php echo $userObj->getCountryName($univerCountry)?> </td>
</tr>
<tr>
<td align="left" > <strong>E-mail of the Head of the Institution /HOD</strong> </td>
<td align="left" ><?php echo $univerEmail?></td>
</tr>
<tr align="center">
<td colspan="2" bgcolor="#CCCCCC" ><strong><u> APPLICANT’S INFORMATION</u> </strong></td>
</tr>
<tr>
<td colspan="2" align="left" ><table width="100%" border="0">
<tr>
<td width="36%"><strong> E-mail </strong></td>
<td width="48%"><?php echo $email?></td>
<td width="16%" rowspan="9" class="thickb"><p align="center"> Affix Passport Size Photo </p>
<p align="center"> (attested by Head of the Institute) </p></td>
</tr>
<tr>
<td> <strong>Name </strong></td>
<td><?php echo $firstName;?> <?php echo $middleName;?> <?php echo $lastName;?></td>
</tr>
<tr>
<td align="left" ><strong> Participant Status </strong></td>
<td align="left" ><?php if($participantStatus==1){ echo "Teacher";} else {echo "Student"; }?>
</td>
</tr>
<tr>
<td align="left" ><strong> Areas of Interest </strong></td>
<td align="left" ><?php echo $areaOfInterest ?>
<?php if($areaOfInterest=="Others"){ echo "(".$aeraOfInterOther.")";}?></td>
</tr>
<tr>
<td ><strong> Proficiency in English</strong> </td>
<td><?php if($profInEnglish==2){echo "Below Average";}else if($profInEnglish==1){echo "Average";}else {echo "Very Good";}?> </td>
</tr>
<tr>
<td colspan="2" align="center" ><table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="43%" align="left"><strong> Date Of Birth </strong></td>
<td width="13%"><?php echo $DATEOFBIRTH[2]."/".$DATEOFBIRTH[1]."/".$DATEOFBIRTH[0]?></td>
<td width="12%" align="left" ><strong>Gender </strong></td>
<td width="32%" align="left" ><?php if($gender==0){?>
Male
<?php }?>
<?php if($gender==1){?>
Female
<?php }?></td>
</tr>
</table></td>
</tr>
<tr>
<td><strong> Address for Correspondence </strong></td>
<td><?php echo str_replace("\n","<br />",$commAddress)?></td>
</tr>
</table></td>
</tr>
<tr>
<td colspan="2" align="right"><table width="100%" border="0" cellspacing="0" cellpadding="1">
<tr>
<td width="7%"><span > <strong>Phone(with STD) </strong></span></td>
<td width="20%"><?php echo $phone?></td>
<td width="4%" align="right" ><strong>Mobile</strong> </td>
<td width="19%" align="left"><?php echo $mobile?></td>
</tr>
</table></td>
</tr>
<tr align="center" bgcolor="#CCCCCC">
<td colspan="2" ><strong> <u>Health Information for Emergency</u> </strong></td>
</tr>
<tr>
<td align="left" > <strong>Blood Group </strong></td>
<td align="left" ><?php if($bloodgroup){echo $bloodgroup;} else {echo "N/A";}?></td>
</tr>
<tr>
<td align="left" ><strong> Major disease (if any) </strong></td>
<td align="left" ><?php if($disease){echo $disease;} else {echo "N/A";}?></td>
</tr>
<tr>
<td align="left" ><strong> Emergency Contact</strong> </td>
<td align="left" > </td>
</tr>
<tr>
<td colspan="2" align="left" ><table width="100%" border="0">
<tr>
<td width="27%"><strong>Name</strong> </td>
<td width="12%"><?php if($emergencyName){echo $emergencyName;} else {echo "N/A";}?></td>
<td width="20%"><strong>Relationship</strong></td>
<td width="41%"><?php if($emergencyRelation){echo $emergencyRelation;} else {echo "N/A";}?></td>
</tr>
</table></td>
</tr>
<tr>
<td colspan="2" align="left" ><table width="100%" border="0">
<tr>
<td><strong>Phone</strong></td>
<td><?php if($emergencyPhone){echo $emergencyPhone;} else {echo "N/A";}?></td>
<td><strong>Mobile</strong></td>
<td><?php if($emergencyMobile){echo $emergencyMobile;} else {echo "N/A";}?></td>
<td><strong>Email</strong></td>
<td><?php if($emergencyEmail){echo $emergencyEmail;} else {echo "N/A";}?></td>
</tr>
</table></td>
</tr>
<tr align="center" bgcolor="#CCCCCC">
<td colspan="2" align="center"><strong><u> ACADEMIC RECORD OF THE APPLICANT </u></strong></p></td>
</tr>
<?php if($participantStatus==0){ ?>
<tr>
<td colspan="2" align="left" <?php if($participantStatus==0){ ?>class="thickb" <?php }?>><table width="100%" border="0" >
<tr>
<td width="49%"><strong> Current Program of Enrollment </strong></td>
<td width="51%"><?php echo $currentProgEnroll; ?></td>
</tr>
<tr>
<td><strong> Year of Study </strong></td>
<td><?php echo $yearOfStudy; ?></td>
</tr>
<tr>
<td colspan="2"><p><strong> Record of the LAST TWO Exams </strong></p>
<table width="100%" border="1">
<tr>
<td valign="top"><strong> Name of Exam </strong></td>
<td valign="top"><strong> University / Board </strong></td>
<td align="center" valign="top"><strong> Year of Passing </strong></td>
<td align="center" valign="top"><strong> Percentage/ CGPA / SGPI Obtained
<br>
(Enclose Attested <u>Certificate</u>) <br>With Hard Copy</strong></td>
<td valign="top"><strong> Division / Rank in Class</strong></td>
<td><strong> Size of the Class<br> (no. of students) </strong></td>
</tr>
<tr>
<td><?php echo $nameOfExam1?></td>
<td><?php echo $university1?></td>
<td align="center"><?php echo $yearOfPassing1;?></td>
<td align="center"><?php echo $percentage1?></td>
<td><?php echo $division1?></td>
<td><?php echo $sizeOfStudent1?></td>
</tr>
<tr>
<td><?php echo $nameOfExam2?></td>
<td><?php echo $university2?></td>
<td align="center"><?php echo $yearOfPassing2?></td>
<td align="center"><?php echo $percentage2?></td>
<td><?php echo $division2?></td>
<td><?php echo $sizeOfStudent2?></td>
</tr>
</table></td>
</tr>
<tr>
<td valign="top"> <strong>Any other Achievements, Honours obtained </strong><br />(<u>Attach TYPED / HANDWRITTEN 1 PAGE SEPARATELY)</u></td>
<td align="left" valign="top"><?php echo $Achievements?></td>
</tr>
</table></td>
</tr>
<?php }?>
<?php if($participantStatus==1){ ?>
<tr align="center" bgcolor="">
<td colspan="2" ><p align="center"><strong>Enclose relevent Acedemic documents/ attested Certificates with Hardcopy </strong></p></td>
</tr>
<tr>
<td colspan="2" align="left" valign="top"<?php if($participantStatus==1){ ?>class="thickb" <?php }?> ><table width="100%" border="0">
<tr>
<td colspan="2"><table width="1000px" border="0">
<tr>
<td width="20%"> <strong>Highest Degree Obtained </strong></td>
<td width="18%"><?php echo $highestDegree?></td>
<td width="21%"><strong>University/ Institute Name </strong></td>
<td width="16%"><?php echo $universityName?></td>
<td width="7%"><strong> Year</strong></td>
<td width="18%"><?php echo $year?></td>
</tr>
</table></td>
</tr>
<tr>
<td colspan="2"><table width="100%" border="0">
<tr>
<td width="38%"> <strong>Total experience in years </strong></td>
<td width="10%"> <strong>Teaching</strong> </td>
<td width="26%"><?php echo $yearinTeaching?></td>
<td width="8%"> <strong>Research</strong> </td>
<td width="18%"><?php echo $yearInResearch?></td>
</tr>
</table></td>
</tr>
<tr>
<td colspan="2"><table width="100%" border="0">
<tr>
<td width="38%"> <strong>No. of publications in National / International </strong></td>
<td width="11%"> <strong>Journals</strong> </td>
<td width="9%"><?php echo $noOfPubJournals?></td>
<td width="17%"> <strong>Conferences</strong> </td>
<td width="6%"><?php echo $noOfPubConferences?></td>
<td width="11%"><strong>Books</strong></td>
<td width="8%"><?php echo $noOfPubBooks?></td>
</tr>
</table></td>
</tr>
<tr>
<td width="38%" valign="top"><strong> Other Academic accomplishments </strong></td>
<td width="62%"><?php echo $otherAcheivments?></td>
</tr>
</table>
</td>
</tr>
<?php }?>
<?php if($participantStatus==0){?>
<tr bgcolor="#CCCCCC">
<td colspan="2" align="center"><strong><u>PROJECT PARTICIPATION / AWARD INFORMATION </u></strong></td>
</tr>
<?php }?>
<tr>
<td colspan="2" align="left" class="thickb" ><?php if($participantStatus==0){?><table width="100%" border="0">
<tr>
<td colspan="2">There will be a <strong> competition of the projects done / presented</strong> by the participants. Those who are interested in competing in the Events, may provide 1-page information on the Project. The participant may bring the Project alongwith them. Selected Entries will be informed through Email and to be displayed at the Conclave Venue. </td>
</tr>
<tr>
<td align="left" ><strong> Type of Project </strong></td>
<td align="left" ><?php if($projectNameYear){if($typeOfProject==0){?> Poster/ Paper Display <?php }?> <?php if($typeOfProject==1){?> Working Model Display <?php }}else {echo "N/A";}?> </td>
</tr>
<tr>
<td width="53%"> <strong>Name of the Project & Year </strong></td>
<td width="47%"><?php if($projectNameYear){ echo $projectNameYear;}else {echo "N/A";}?></td>
</tr>
<tr>
<td> <strong>Broad Area of the Project (Physics, Chemistry, Biology etc.) </strong></td>
<td><?php if($broadArea){ echo $broadArea;}else {echo "N/A";}?></td>
</tr>
<tr>
<td rowspan="4" valign="top"> <strong>Name of the persons who worked on the Project </strong></td>
<td>1.) <?php if($nameOfPerson1){echo $nameOfPerson1;}else {echo "N/A";}?></td>
</tr>
<tr>
<td>2.) <?php if($nameOfPerson2){ echo $nameOfPerson2;} else {echo "N/A";}?></td>
</tr>
<tr>
<td>3.) <?php if($nameOfPerson3){ echo $nameOfPerson3;} else {echo "N/A";}?></td>
</tr>
<tr>
<td>4.) <?php if($nameOfPerson4){ echo $nameOfPerson4;} else {echo "N/A";}?></td>
</tr>
<tr>
<td> <strong>Name of the Guide </strong></td>
<td><?php if($guideName){ echo $guideName;} else {echo "N/A";}?></td>
</tr>
<tr>
<td> <strong>How long did you worked on the Project </strong></td>
<td><?php echo $howLong?></td>
</tr>
<tr>
<td colspan="2"><table width="100%" border="0">
<tr>
<td width="37%"><strong>Was it displayed anywhere (Y / N) </strong></td>
<td width="13%"><?php if($displayed==1){ echo "Yes";}else{echo "No";} ?></td>
<td width="10%"><strong>Where</strong></td>
<td width="40%"><?php echo $displayedWhere?></td>
</tr>
</table> </td>
</tr>
<tr>
<td> <strong>If displayed, did it win any Awards (Yes / No) </strong></td>
<td><?php if($winAward==1){ echo "Yes";}else{echo "No";} ?></td>
</tr>
<tr>
<td> <strong>If Yes, name of Award & awarding Institution </strong></td>
<td><?php echo $nameofAward?></td>
</tr>
<tr>
<td align="left" valign="top"> <strong>Description of the Project </strong><br />
<u>(To be attached separately on blank A4 paper)</u></td>
<td align="left" valign="top"><?php echo str_replace("\n","<br />",$descriptionOfProject)?></td>
</tr>
<tr>
<td valign="top"><strong>Facilities needed for display of the Project at Conclave Venue (Power, Tables, Wall space etc.) </strong></td>
<td valign="top"><?php echo $facilityNeeded?></td>
</tr>
<tr>
<td valign="top"> <strong>I Declare that Project/Equipment is SAFE/ NON HAZARDOUS</strong></td>
<td valign="top"><?php if($projectNameYear){if($projectSafe==1){ echo "Yes";}else{echo "No";}}else {echo "Yes";} ?></td>
</tr>
</table>
<?php } else {?>
<table width="100%" border="0" >
<tr>
<td width="57%" align="left" valign="top"> Innovation done in the field of Teaching, Research or any other Contribution </td>
<td width="43%"><?php echo str_replace("\n","<br />",$innovationDone)?></td>
</tr>
</table><?php }?>
</td>
</tr>
<tr>
<td colspan="2" align="right"></td>
</tr>
<tr>
<td colspan="2" class="thickBorder"><table width="100%" border="0">
<tr>
<td colspan="4"><p align="center"><strong> <u>DECLARATION</u> </strong></p></td>
</tr>
<tr valign="top">
<td colspan="4" align="center" class="style6"> I declare that this would be my first participation in Science Conclave and that I <u>will attend </u> the Conclave during Dec 08 – 14, 2013
<p align="center"> <strong><u>(Full duration, failing which Participation Certificate may be denied to me)</u></strong> </p></td>
</tr>
<tr>
<td width="15%"><strong> Name</strong>:</td>
<td width="31%"> </td>
<td width="37%"><strong>Signature</strong>:</td>
<td width="17%"><strong>Date:</strong></td>
</tr>
<tr align="center">
<td colspan="4"><strong><u> CERTIFICATE OF NOMINATION</u></strong> </td>
</tr>
<tr valign="top">
<td colspan="4">
<p>It is certified that:</br>
1) The applicant is a bonafide student / teacher / researcher of this Institute/University </br>
2) The applicant has NOT PARTICIPATED in previous Science Conclaves at IIIT-A <br />
3) <?php if($participantStatus==0){?>The particulars of the applicants given in the form (Rank, Percentage, Marks, Publications etc.) are verified as per our official records and Photograph/Identity of the Applicant is attested. <?php }else{?>The Particulars of the Applicants given in this form are verified as per our official records and Photograph/Identity of the Applicant is attested<?php }?><?php if($participantStatus==0){?><br>
4) The Project/Equipment proposed by the Applicants is <strong>HEREBY CERTIFIED TO BE TOTALLY SAFE/ NON HAZARDOUS</strong><?php }?></td>
</tr>
<tr>
<td><strong> Date:</strong></td>
<td>........../........./.............</td>
<td><strong>Signature and Seal: <br> (Head of the Institute/University)</strong></td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
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</tr>
<tr ><td colspan="2"><p align="center"><strong> <u>NECESSARY INFORMATION FOR PARTICIPANTS</u></strong></p></td>
</tr>
<tr ><td colspan="2">
<p><strong> -[A] CONCLAVE SCHEDULE (tentative) </strong></p>
<p><strong> Arrival of Participants : December 07, 2013 </strong></p>
<p><strong> Start of Science Conclave : 09:00 AM December 08, 2013 </strong></p>
<p><strong> Close of Science Conclave : 05:30 PM on December 14, 2013 </strong></p>
<p><strong> Duration of Sessions : 09:00 AM to 06:00 PM daily </strong></p>
<p><strong> Cultural Programs/Others : 07:30 PM to 09:00 PM on selected days </strong></p>
<p><strong> Sight Seeing to City : on selected days and timings (to be announced locally) </strong></p>
<p><strong> Departure of Participants : 08:00 PM on December 14, 2013 and afterwards</strong><strong></strong></p>
<p><strong> [B] OTHER INFORMATION </strong></p>
<p>-Full attendance from each participant is must during conclave sessions from December 08-14, 2013 </p>
<p> -Submission of the feedback form is mandatory by every participant </p>
<p> -Opportunities for Informal interactions with Nobel Laureates/Scientists will be facilitated </p>
<p><strong> -The Institute reserves the right to screen, select and restrict the total number of participants and / or participants from any individual source.</strong></p>
<p><strong> -Accommodation at Allahabad </strong></p>
<p> Accommodation for participants will be provided by organizers of Science Conclave 2013 at Allahabad, INDIA. </p>
<p> </p>
<p> -<strong>Other related Information/Help Desk/Sight Seeing etc. </strong></p>
<p> -For further details keep visiting conclave website at <a href="http://scienceconclave.iiita.ac.in">http://scienceconclave.iiita.ac.in</a>. </p>
<p> -For any queries, mail can be dropped at: <a href="mailto:scienceconclave@iiita.ac.in">scienceconclave@iiita.ac.in</a></p>
<p> -<strong> LIST of SELECTED PARTICIPANTS would be displayed on the WEBSITE</strong></p>
<p><strong> THE CONCLAVE MATERIAL, TOKEN GIFTS AND PARTICIPATION CERTIFICATES WILL BE PROVIDED TO THE PARTICIPANTS.</strong></p>
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<p><strong> ADDITIONAL ATTRACTIONS </strong></p>
<p><strong> - SKY / STAR WATCHING THROUGH TELESCOPES WILL BE FACILITATED </strong></p>
<p><strong> - POSTER / MODEL PRESENTATION & ESSAY WRITING COMPETITIONS ON SCIENCE TOPICS WILL BE ORGANIZED, INFORMATION ABOUT WHICH WOULD BE PROVIDED</strong></p>
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<td valign="top"><?php if($forrecordId) {?><input type="button" value="Print this page" onclick="window.print();"><input type="hidden" name="forrecordId" value="<?php echo $forrecordId;?>" /><?php } ?></td>
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