AS&S Candidate Application Form: India

...............CANDIDATE CONTACT INFORMATION.............





Suggestion:
For each question candidate should enter the exact information and some of the fields in this section may have to be re-entered, e.g. School Name. In order to facilitate the process, consider using a text editor to contain the repeated information. Then use copy and paste to enter the repeated information into the appropriate fields.
Candidate's Full Name

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* 1. Candidate's Full Name

Candidate's Age & Date of Birth(DOB)

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* 4. Candidate's Age & Date of Birth(DOB)

Candidate's Email Address

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* 7. Candidate's Email Address

If Candidate is a current member of AS&S, what is the email Address assigned to you?
(Note: Your email will end with @asciencesociety.org)

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* 10. If Candidate is a current member of AS&S, what is the email Address assigned to you?
(Note: Your email will end with @asciencesociety.org)

Candidate's Residential Address

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* 11. Candidate's Residential Address

Candidate's Contact Address (If different from Residential address)

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* 12. Candidate's Contact Address (If different from Residential address)

Candidate's Phone Number (Land Line)

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* 13. Candidate's Phone Number (Land Line)

Candidate's Cell/Mobile Phone Number

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* 14. Candidate's Cell/Mobile Phone Number

Please provide Emergency Contact's Full Name

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* 15. Please provide Emergency Contact's Full Name

Please provide an Emergency Contact Number(Land line & Moblie Phone Number)

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* 16. Please provide an Emergency Contact Number(Land line & Moblie Phone Number)

Candidate's Father/local Guardian's Name, Address, Email and Phone information

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* 17. Candidate's Father/local Guardian's Name, Address, Email and Phone information

Candidate's Grade Level/Rank/Class/Percentage of marks obtained in the current or last Exam/Assessment.

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* 18. Candidate's Grade Level/Rank/Class/Percentage of marks obtained in the current or last Exam/Assessment.

......................................CANDIDATE'S DEMOGRAPHIC INFORMATION.......................................




Besides English, list other languages you know

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* 25. Besides English, list other languages you know

Provide your family Ration Card Number

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* 26. Provide your family Ration Card Number

What is the name of your School/College/University/Institute

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* 30. What is the name of your School/College/University/Institute

Enter your School/College/University/Institute address

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* 31. Enter your School/College/University/Institute address

Please enter your current rank and/or Percentage of marks in your present or last exam/assessment

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* 32. Please enter your current rank and/or Percentage of marks in your present or last exam/assessment

Are You or Your family members being coverd under any insurance scheme, please specify the Type of Insurance Scheme you are involved into Select all that apply.

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* 34. Are You or Your family members being coverd under any insurance scheme, please specify the Type of Insurance Scheme you are involved into Select all that apply.

How many Siblings do you have

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* 37. How many Siblings do you have

......................CANDIDATE'S ACADEMIC INFORMATION..........................




Would you be the FIRST in your family to finish (Tick mark all that apply)

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* 39. Would you be the FIRST in your family to finish (Tick mark all that apply)

What Extracurricular activities are you interested in?

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* 40. What Extracurricular activities are you interested in?

What are your two highest Career Choices?

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* 41. What are your two highest Career Choices?

Choice for your area of research:
In order to best match you with a mentor, please indicate your First (1st), Second (2nd), Third (3rd), Fourth (4th) and Fifth (5th) preferences.

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* 43. Choice for your area of research:
In order to best match you with a mentor, please indicate your First (1st), Second (2nd), Third (3rd), Fourth (4th) and Fifth (5th) preferences.

  Highest - First Second Third Fourth Lowest - Fifth
Agriculture & Natural Resources
Astronomy
Architecture & Environmental Design
Atmospheric Science
Computer Science
Engineering
Bio/Informatics
Biotechnology
Ecological Science
Environmental Science
Medical Sciences
Epidemiology
Statistics
Robotics
Anthropology
Psychology
Science Reporting/ Writing
Science Advocacy
Legal Science (Patent Law, etc)
Forensic Science
Communications
Linguistic Sciences
Library Science
Nutritional Science
Health Professions
Actuarial Science
Social Sciences
Botanical Sciences
Animal Husbandry
Veterinary Medicine
Complementary Medicine (Naturopathy, Chiropractic, Herbalism, Traditional Chinese Medicine, Unani, Ayurveda, Medicine, Yoga, Biofeedback, Hypnosis, Homeopathy, Acupuncture, Nutritional based therapies, etc.)
What are your long term career goals?

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* 44. What are your long term career goals?

..............CANDIDATE ADMINISTRATIVE INFORMATION.................




What is the name of the person who recommended you for membership?

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* 45. What is the name of the person who recommended you for membership?

What Institute or organization was the person recommending from

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* 46. What Institute or organization was the person recommending from

What is the email of the person who recommended you?

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* 47. What is the email of the person who recommended you?

In what year were you recommended (as yyyy)?

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* 48. In what year were you recommended (as yyyy)?

Enter you Registration Number

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* 52. Enter you Registration Number

Enter Registration Date as Day/month/Year

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* 53. Enter Registration Date as Day/month/Year

Registration Date:
CERTIFICATION OF ACCURACY
I, the undersigned, am of legal adult age and certify that all information on this form is true and correct to the best of my knowledge and understanding. I understand that my statements are subject to verification. I further understand that any false statements may subject me to criminal prosecution under Indian Penal Code(IPC).
I agree and accept that I will abide by all applicable rules and regulations of this program.
If you agree to all of the above, type your full name, state that you are the applicant, or the legal adult on behalf of the applicant, who completed this form.
Type one or the other of the following responses shown below:
I, (your name), am the applicant of legal adult age who has completed this form and have read, understood and agree to all the above.
I, (your name), am the adult of legal adult age, who has completed this form on behalf of the applicant and have read, understood and agree to all the above.
Enter your response as indicated above

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* 54. Enter your response as indicated above

Date Application Completed

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* 55. Date Application Completed

Completed
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