APPENDIX B

Form A.2-3
2009-10 Revision
TECHNICAL COOPERATION SCHEME OF COLOMBO PLAN
(Sponsored by the Ministry of Finance, Government of India)

APPLICATION FORM

Registration No.
(for official use only by TC Division )

3x4 cm

Photograph
PART- I
Country : _____________________ Course : _______________________________
Commencing from : _____________ to ____________
Institute : _____________________
DD/MM/YYYY DD/MM/YYYY

1. Personal Particulars

Name(s):

Surname:

Sex (tick one): MALE / FEMALE

Marital Status:

Date of Birth:

Date - Month - Year

Nationality:

Passport No.:

Address: Office Home

Tel Nos.
Mobile/Cell :
Fax :
E-mail :
Special dietary needs, if any :

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Person(s) to be notified in case of Emergency
Official Contact Personal / Family Contact
Name :
Address:
Tel Nos:
Mobile /Cell :
Fax:
E-mail:

2. Professional Particulars
Educational Qualification/(s)
Degree / Diploma / Certificates Year Name of Educational Institute
1
2
3
4

Professional Qualification(s), if any:

Professional Qualification (s) Year Name of Educational Institute
1
2
3
4

Employment Records:
Name of Employer / Department / Company Position Year Area / Nature of Work
1
2
3
4

Are you an employee of: (Tick appropriate box)

a. Government b. Semi-government/Parastatal
c. Private company d. Self-employed

Details of present employer

Name / address :
Tel. No. :
E-mail :

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3. Have you ever attended a course sponsored by the Government of India? (Tick one) YES /NO

4. If answer to 3 is yes, details of the courses _______________________________________

Details of course(s) attended, if any, outside your country

Country Course Details Year Duration

5. Please write in your own words, reason(s) for attending the training course

6. Certification of English language proficiency (by recognized Institute / authority)

Good Basic Remarks

Spoken
Written

Mother tongue / Native language : ____________________/ Other language(s), if any :_________________

English Language test ___________________________ Tel. Number : ________________ __

administered by :
___________________________ E-ma il :
Address :
___________________________ ________________________
_______ __________________ Date and Signature : ____________

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 MOF / TCS - Application
PART - I (a)

MEDICAL REPORT

(to be completed by an authorized physician )

(i) Name of Applicant:
(ii) Age:
(iii) Sex: (Male / Female)
(iv) Height (cm):
(v) Weight (kg):
(vi) Blood Group:
(vii)Blood Pressure:

1. Is the person examined in good health at

present ?
2. Is the person examined physically and mentally
able to carry out intensive training away from home?
3. Is the person free of infectious diseases (AIDS,
tuberculosis, trachoma, skin diseases etc),Yellow fever
certificate (in case of people coming from that region or
as laid out in WTO regulations).
4. Does the person examined have any medical
condition or defect which might require treatment
during the course ?
5. List any abnormalities indicated in the chest X ray.
6. Pregnancy Test ( for women ):

I certify that the applicant is medically fit to undertake a training course in India.
Name of Physician : __________________________________________________________
Registration No. : ____________________________________________________________
Address of Clinic / Hospital : ___________________________________________________
and City / Town (printed) : _____________________________________________________
Telephone (printed) : ________________________________________________________
E mail : _____________________________ Date __________________________________
Signature of Physician __________________ Seal of Clinic/Hospital:_________________

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IMPORTANT NOTICE

• Please read the form carefully. The application will be automatically rejected if any
column is incomplete / blank.

• Declaration by the candidate and the recomme ndations from employer, if any, are
compulsory pre- requisites.

• Working knowledge of the English language is also a pre-requisite except for English
language and language related courses.

• Candidates who leave the course midway for personal reasons without prior
permission of the Ministry of Finance or remain absent from the programme without
sufficient reasons are expected to refund the cost of training and airfare to
Government of India.

UNDERTAKING BY THE APPLICANT

I, _____________________________________________________________________
(Name, Middle name, Family name)

of (country)_________________________________________ certify that information provided by

me in this form is true, complete and correct.

I also certify that I have read the course brochure and that I am aware of the course contents and
living conditions in India *.

I have not applied for any other training course during the above mentioned training period.

If accepted for the training programme, I undertake to:

(a) carry out such instructions and abide by such conditions as may be stipulated by both
the nominating and sponsoring Governments, in respect of the training;
(b) follow the full course of study or training and abide by the rules of the university or
institutions or establishment in which I undertake to study or gain training;
(c) submit periodic assessment / tests conducted by the Institute (progress report which
may be prescribed);
(d) refrain from engaging in political activities, or from any form of employment for profit
or gain;
(e) return to my home country at the end of my course of study or training;
(f) I also fully undertake that if I am granted a training award it may be subsequently
withdrawn if I fail to

make adequate progress or for any other sufficient cause determined by the host
Government.
Date:
Place:

(SIGNATURE OF THE APPLICANT)

Name: _________________________________
* Details of the course are on the website of the Institute or can be obtained from them by e-mail.

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 PART – II
To be completed by the authorized official of the
Nominating Government

I, ________________________________________________ on behalf of the Government

of___________________________________ certify that:

(a) I have examined the educational, professional and other certificates quoted by the
nominee in Part – I of this form and I am satisfied that they are authentic and relate to
the nominee.
(b) I have examined the medical certificates and X-ray reports produced by the nominee
which state that he is medically fit and free from any infectious disease such as AIDS
and yellow fever and that having regard to his physical and mental history there is no
reason to suppose that the nominee is other than fit to undertake the journey to India
and to remain under training in that country.
(c) The nominee has sufficient knowledge of spoken and written English to enable him to
follow the course of training for which he / she is being nominated.
(d) The nominee has not availed of TCS training facilities earlier in India.

I nominate Mr./Mrs./Miss__________________________________________ on behalf of the

Government of________________________________________________
Name of Nominating Authority:
Designation:
Address:
Date:
Place:

Signature
(With seal)
Name and Designation
(in block letters)

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 PART - III Restricted

For official use only

Verification by Mission
Name of the Country : __________________________________________________
Name of the Nominee: __________________________________________________
Designation: _________________________________________________ __________
Present Assignment: _________________________________________________ ___
Employer/Department: _________________________________________________
Address: _________________________________________________ _____________
Name of Institute : ___________________________________Sl.No__________ ____
Name of the Course : ___________________ ________________Sl.No____________
Dates and Duration : _______________to_______________ ____________________
Weeks/Months/Yr

Certified that the nominee has been interviewed by HOM / India based dealing officer and
found eligible to undertake the course. Also certified that the nominee has not availed of
training
facilities under TCS earlier.
Remarks ( if any ):

Signature
Name & Designation of
Officer dealing with TCS

Recommendation by HOM

I hereby recommend Mr. /Mrs. / Ms._____________________________________________

for the course under TCS Programme

Signature of HOM / CDA

Seal / Stamp
DATE :
STATION :

It is the responsibility of the Indian Mission to ensure that :

(i) One copy of the form, duly completed in all respects, is forwarded to FT Division
(ii) The form should reach FT Division, Ministry of Finance at least two months before
commencement of the course (applications received after the deadline will not be accepted).

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