ࡱ>  O$bjbjNN <,w,wLZZ$A%E%E%EPuElE|Ai]]G gJ(JJJjKM O\\\\\\\S^`L\OjKjKOO\OJJ#]OOOOJJ\OO\OOVWTX̌%EO:LX X9]0i]XXTAaOAaXOXOOOAA.%EAA%EZ :    Registration Form We are seeking participants between the age of 18-25 to apply, especially those who have an interest in learning how to scale up grass roots social and business initiatives. If your application is successful, you will have the opportunity to meet and learn from Indias real heroes and pick up invaluable, career defining skills and participate in a life-changing event that is Jagriti Yatra. Upon submission, your application will go through an extensive selection process. To stand a good chance to be selected, we encourage you to think carefully about your answers to the questions asked on the application form below and include as much detail as possible. You can complete the form in two different ways. The form has been designed to enable you to fill it out on a computer using Microsoft Word and then print it out. Alternatively you can print it out first and fill it in by hand. English is preferred although you are welcome to use Hindi, Tamil, Punjabi, Marathi or Bengali. When complete, please either email your application to  HYPERLINK "mailto:registration@jagritiyatra.com" registration@jagritiyatra.com or post it to Gitanjali Banerjee, Jagriti Yatra, 315 Balgovind Wadi, New Prabhadevi Road, Prabhadevi, Mumbai - 400 025, India. Part 1 Title:Mr.  FORMCHECKBOX  Mrs.  FORMCHECKBOX  Dr.  FORMCHECKBOX  Prof.  FORMCHECKBOX  First Name: FORMTEXT      Surname: FORMTEXT      Email Address: FORMTEXT      Mobile: FORMTEXT      Landline phone number: FORMTEXT      Postal Address: FORMTEXT       PIN/ZIP Code:  FORMTEXT      Country:  FORMTEXT      Age:  FORMTEXT      Gender: Male  FORMCHECKBOX  Female  FORMCHECKBOX  Part 2 The Yatra is expected to cost around 400 or Rs. 32000 per person. We expect sponsorship funds to cover the costs of many participants - but not all. We therefore welcome donations from participants that can provide for their costs. This will help allocating the sponsorship funds for deserving participants that cannot afford the same. Will you be able to contribute towards your costs of the Yatra [Note that your choice will not impact your selection] Agree  FORMCHECKBOX  Disagree  FORMCHECKBOX Level of EducationHigh School  FORMCHECKBOX  Graduate  FORMCHECKBOX  Post Graduate  FORMCHECKBOX What is your vocation? Select only one.Agriculture  FORMCHECKBOX  Army/Air force  FORMCHECKBOX  Arts/Media  FORMCHECKBOX  Banking  FORMCHECKBOX  Corporate  FORMCHECKBOX  Doctor  FORMCHECKBOX  Engineer  FORMCHECKBOX  Entrepreneur  FORMCHECKBOX  Environment  FORMCHECKBOX  Education/Teaching  FORMCHECKBOX  Government Service  FORMCHECKBOX  Home maker/House wife  FORMCHECKBOX  Information Technology  FORMCHECKBOX  Politician  FORMCHECKBOX  Lawyer  FORMCHECKBOX  Research Scientist  FORMCHECKBOX  Scientist  FORMCHECKBOX  Social worker  FORMCHECKBOX  Student  FORMCHECKBOX  Unemployed  FORMCHECKBOX  Other  FORMCHECKBOX  Would you like to be a social or business entrepreneur? Business  FORMCHECKBOX  Social  FORMCHECKBOX  No  FORMCHECKBOX We are expecting facilitators to fund themselves by donating Rs.32000 or 400. Would you like to be a : Facilitator  FORMCHECKBOX  Participant  FORMCHECKBOX If you have stated that you would like to be a facilitator then please describe your professional experience and supply us with two references (name, their professional relationship to you, email address or phone number): FORMTEXT       Part 3 Who is your role model in life? State their full name and why you admire them (maximum 500 words).  FORMTEXT       Have you already done something, which demonstrates social or business entrepreneurship? (Maximum 1000 words) This could be a small scale school or college project or venture, a hobby you converted in to a business, or something beneficial for your local community.  FORMTEXT       In your opinion, what is the single biggest challenge that India faces in the next decade? (maximum 1000 words)  FORMTEXT       What will be your contribution towards addressing the challenge you mentioned above? Describe your proposed solutions in detail. (Maximum 1000 words)  FORMTEXT       Why do you think you should be selected to be on Jagriti Yatra? (Maximum 250 words)  FORMTEXT       I would like to receive further information about Jagriti Yatra and events related directly to it.  FORMCHECKBOX  I do not mind my details being passed on to carefully selected third parties who may contact me about products or services which are not related to the Jagriti Yatra.  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