Four day Training ProgramOn R&R and CSR, Feb. 16 – 19, 2016

Registration Details

Registration Fee: The registration Fee of Rs. 5000 /- (Rupees Five Thousand Only)can be paid online to State Bank of India, Fortune Tower Branch, Bhubaneswar.A/c Name: Xavier Institute of Management PSRA, A/c No. 34916884919, IFSCCode - SBIN0004414

The printout of the fee paid can be sent along with the Registration Form. Alternativelythe fee can also be paid by issuing a demand draft in favor of Xavier Institute ofManagement PSRA, payable at Bhubaneswar.

The registration fee includes participation, reading materials, tea / snacks and lunch formaximum 20 participants.

The Last Date of Registration is January 30, 2015

For any other query or information please contact:

Ms. Sushila NayakCentre for Resettlement, Rehabilitation and Corporate Social Responsibility (CRRCSR)Room No 204, 2nd Floor, Administrative BuildingXavier Institute of ManagementXavier UniversityBhubaneswar, Odisha

Mobile- 9437018915Landline- 0674-6647894Email- sushila@ximb.ac.in

Four day Training ProgramOn R&R and CSR, Feb. 16 – 19, 2016

Registration Form

Registration Information (Please write in Block Capital Letter)

Full Name: …………………………………………………………………………………

Designation: ……………………………………………………………………………….

University / Company Name:……………………………………………………………….

Type of Organization: Academic Corporate Govt. Dept. NGOs Others

Postal Address: ………………………………………………………………………………….

……………………………………………………………………………………………………

City ……………………..... State ……………………….. Pin Code ………………………..

Sex: Male Female Date of Birth:

Telephone ………………………………….. ( R ) ……………………………………………

E- Mail …………………………………………………………………………………………

I acknowledge that I want to register for the Inclusive India Forum 2016 on January 22, 2016.

Date: …………………… Signature: ………………………