RURAL COMPUTER TRAINING ACADEMY

Sharing Rural People Skills Development Programme with Govt. of Karnataka

H.O.: Bangalore D.O.: Mangalore

Admin. Office: 3/301, Shree Laxmi Building Navoor Post Bantwal Tq, Mangalore, Karnataka (India) - 574211

Email: ruralcmptr08@gmail.com

Application for IT Centre

Fill out this form and attach supporting documents/profile.

1. Name of Institution *

4. E-mail Address *

2. Postal Address *

3. Date of License from Panchayath/Municipality/Corporation

7. Established in the year

5. Ownership / Status *

IndividualPartnershipCo-operativeCharitable

6. Telephone Numbers

Office

Residence

Mobile *

Fax

Head of Institution Details

8. Name of the Head of Institution *

10. Qualification of the Head

9. Residential Address

11. Working Experience

12. Assessment of the Centre

a) Location (prime location/on road etc.)

b) Property Status (Owned/Lease/Rent/Commercial/Residential)

Please attach copies of lease/rent deed

c) Landmarks of the Location (ground floor/second floor if any)

13. Existing Facilities

a) Total Carpet Area

b) Number of Classrooms

c) Seating Capacity & Furniture

d) Total Computers with Configuration

e) Max Students Trained at One Time

g) Internet Connection & Type

f) Other Details of Computer Lab

h) Modems/Printers & Configuration

i) UPS or Generator for Power Backup

j) Toilet, Drinking Water & Basic Amenities

14. Staff Details

Name	Qualification	Age	Experience	Action

15. Inspection Fee Details

Amount (Rs)

D.D. No

Dated

Name of Bank

Payable At

We are agreed to all the terms and conditions of The Rural Computer Training Academy and hereby signed. *

Date *

Name of Applicant (Head of Institution) *