Jagriti Yatra2015

We welcome your decision to participate in Jagriti Yatra 2015. To participate in this Yatra you need to fill up this Application form.

Your form will go through a stringent, pre-designed Selection process before the final selection. To improve your chances of selection, answer all the questions carefully and in detail. Submit your application well in advance of the last date to improve your chances of selection

For submitting your application you have two options. You may post the hand-written form or type in MS Word and e-mail it to us.

Please Note:

The aim of this application is to judge your ability to become a genuine change - maker. Please fill in the application form honestly and respecting the spirit of the Yatra.

  1. Incomplete applications will be rejected.
  2. One candidate can submit only one form. If two applications are submitted both will be rejected.
  3. Do not exceed the word limit.
  4. Do not cut-paste from the internet or borrow ideas from others. We want your original thoughts.
  5. Random checks are carried out to confirm the veracity of your application. Dishonest applications will result in debarring the candidate.

Address E-mail

Jagriti Sewa Sansthan (Please mention ‘registration form’ in subject)

B 5,Green Acres Housing Society,

Off Din Quarry Road, Panjarpole, Contact No. 022 64535354 / 022 25550936

Deonar, Mumbai 400 088

Jagriti Yatra 2015

Registration

Name: (First Name) ______

(Last Name) ______

Contact no. : ______

Alternate Contact no. :______

E-mail address ( if any) : ______

How did you first find out about the Yatra? (Newspaper Article, Newspaper Ad, Website, Company announcement, School/College poster, Blog, From a friend, JADE)______

Application Form

Date of Birth : ----- DD, ----- MM , ----- Year

Complete permanent postal address: (with City, District, State and pin code) ______

PermanentCountry : ______

Permanent State: ______

Permanent District : ______

Permanent City/Town: ______

Complete current postal address: (with City, District, State and pin code) ______

Current Country : ______

Current State : ______

Current District : ______

Current City : ______

Parents/Guardians email : ______

Please specify place you have spent maximum years in:

State : ------(drop down) district : ------(drop down)

Age : ______

Gender : ______

Level of education: (high school/graduate/post-graduate) ______

Qualification and specialization: ______

Occupation: (student/student and working/ working)

If you were to start an enterprise which sector would it be ( select any two): (Agriculture and Agri Business enterprise, Energy and Climate enterprise, Water and Sanitation enterprise, Education and the Knowledge enterprise, Manufacturing enterprise, Health enterprise, Arts/Culture/Sports)

______

Institute studying in: ______

Organization/ Company you work for : ______

Applied for previous yatra: (1997/2008/2009/2010/2011/2012/2013/2014/none) ______

Status of previous application: (selected/rejected/selected but could not participate) ______

Which level sponsorship would you opt for?: ( Sponsorship level 1, Sponsorship level 2, Sponsorship level 3) ------

(Please note that seats for sponsorship level 3 are extremely limited and awarded to the most deserving candidates only. All candidates opting for sponsorship level 2 and 3 will have to produce relevant proof of income. The decision on sponsorship will be taken by our Candidate Sponsorship Panel)The registration and yatri Contribution details are as follows:

1)Sponsorship Level 1 : (I agree to pay registration fees of Rs 5000/- and Yatri Contribution of Rs. 54000/- International Participants agree to pay 1500 USD or 900 GBP)

2)Sponsorship Level 2 :( I agree to pay registration fees of Rs 5000/- and part Yatra fees of 27000/-. I request sponsorship level 2)

3)Sponsorship Level 3 (I agree to pay registration fees of Rs5000/- I am unable to pay the Yatri contribution and request sponsorship level 3)

Are you applying as a Participant or Facilitator? : (Participant / Facilitator) Facilitator option available only if age above 25 : ______

A Participant is a normal Yatri, however enthusiastic and energetic candidates above 25 years of age are urged to take the role of Facilitators. The role of Facilitator is twofold- that of a coordinator and a mentor. The Facilitator is expected to manage his/her group throughout the journey and help them form a cohesive group of learning. He/she will initiate discussions, share knowledge and guide interactions between diverse Yatris.

Your profile ( which includes education background , field of interest and work done if any) (50 words)

(You should write the responses to the questions below on separate sheets of paper. Ensure you stick to the word limit mentioned)

QUESTIONS

  1. Do you have role model/models in your life? (Mention not more than 2 ) What are the qualities/values you admire in her/him/them and would like to follow in your life?(100 words)
  2. What is the biggest challenge you have faced to date? How did you deal with it and what did you learn from it? (200 words)
  3. How would you like to see your career progressin the next 5-10 years and how would it build a better India (100 words)
  4. Have you already done something which demonstrates social or business entrepreneurship or work for a social cause? Describe this. (This could be a school or college project or venture or a hobby you converted into a business, or something beneficial for your local community.) (200 words)
  5. You have selected ‘ ( candidate opts for 2 verticals in the questions above, pick those options’ ) as your Area of Interest. Tell us about one of the challenges faced by your City/ Town/ Village/ Community within any one of the verticals you have selected and how you would solve it. (200 words)
  6. Why do you want to come on the Yatra? (100 words)
  7. If there is any other relevant information you wish to add in terms of your creative skills/awards/achievements, please do so here (200 words)

REFERENCES

This should be a mentor/ teacher/ employer/ business associate who has known you over a significant period and can vouch for your credentials and character.

Name of Reference

How does the reference know you?

Contact details

If you want to participate as a FACILITATOR please fill this section

  1. Why do you want to be a Facilitator on the yatra? (100 words)
  2. Write briefly about your professional experience highlighting your work in youth related programs, social enterprise and any other aspects you feel relevant to the yatra (200 words)
  3. What specific value do you think you will add to the yatra as a Facilitator? (200 words)

SPONSORSHIP FORM

Are you earning: Yes/No

State the no. of family members: ______

Your family’s annual income is: ______

( Less than Rs.3,00,000 / Between Rs 3,00,000 and Rs 7,00,000 / Between Rs 7,00,000 and Rs12,00,000, Above Rs 12,00,000 )

(A copy of any authentic document supporting the income mentioned MUST be attached with form)

( Answer the following questions on a separate sheet of paper)

1. Give your family background: (200 words)

2. Why do you think you deserve sponsorship? (200 words)

ADDITIONAL PERSONAL DETAILS

Mother tongue: ______

Fluent in hindi, english : hindi/ english / both : ______

Hobbies photography/video shooting/ dramatics/writing/reading/other______

Blood group : a rh +ive, a rh –ive, b rh +ive, b rh –ive, o rh +ive, o rh –ive, ab rh +ive, ab rh –ive ______

MEDICAL FORM

Note that you have to undertake a 15 day train journey. This journey is physically and mentally taxing. Please fill in the medical form truthfully. If you have any ailment, consult your doctor on your fitness to travel.

Do you have or are on medication for a prolonged ailment: yes/no

Prolonged Ailment ( if any ) :

Migraine

Epilepsy/convulsions

Psychiatric disorders

Asthama

Thyriod disorders

Heart problems

Ulcers, Piles

Kidney problems

Blood disorders

Gynaecological problems

Hypertension

Diabetes

Liver disorders

Skin disorders

Give details of the ailment you mentioned: ( this will appear only if an option other than “nil” is selected)

Mention significant allergies: yes/no

Give details here : ______

Details of Medical History: ______

Health Precautions and Dietary Restrictions: ______

TERMS OF REGISTRATION, CANCELLATION AND REFUND POLICY FOR JY 2015

Terms of Registration

  1. Jagriti Yatra is a year-long enterprise development program to inspire and empower youth, particularly those from small towns and villages to build India through enterprise. Its Flagship program is a national train journey. This journey is organized on a charitable basis through the Jagriti Sewa Sansthan (JSS) and selected participants are expected to abide by the rules set out for participants for the Jagriti Yatra (JY) ( Code of Conduct to be signed on the 24th of Dec 2015) as well as the following terms of registration for the selection and payment process.
  1. Contribution terms & details:

The payment should reach us within a month from the date of Selection.

The membership fees include Registration towards JY 2015 and one year membership for Jagriti Enterprise Network ( JEN)

Sponsorship Type / Membership contribution
INR / Yatri Contribution INR / Total INR
Sponsorship Level 1 / 5,000.00 / 54,000.00 / 59,000.00
Sponsorship Level 2 / 5,000.00 / 27,000.00 / 32,000.00
Sponsorship Level 3 / 5,000.00 / - / 5,000.00
International applicant / 100USD/50GBP / 1400 USD / 850 GBP / 1500 USD / 900 GBP
  1. Jagriti Sewa Sansthan and its project JY unilaterally reserves all rights to add or modify or cancel any Terms and Conditions of the Yatra at any time without any notice, with or without assigning any reason for the same. This includes rejection of any applicant at any stage of the selection process of the Jagriti Yatra.
  1. JY reserves all rights to seek the evidential support documents to authenticate the information declared or claimed by the applicant in the applications submitted, including age, address, phone, education, financial details etc.
  1. JY at its discretion may also seek the applicant to comply with certain requirements. These include appearing for an interview to know more about the applicant, giving an undertaking to the Jagriti Yatra to cooperate with the program of the Yatra, with proper conduct and behavior all through the journey.
  1. With respect to the selection of an applicant the decision of the selection committee will be final and details of scores/viewing of application forms/or similar information will be not be entertained.
  1. JY holds all the rights of cancellation of selection of the applicant if he/she posts false information on public forums, including social media sites, harming the brand of JY.
  1. JY holds the right to cancel the selection of an applicant if JY finds that the applicant has provided false information or any such information which can harm the brand of JY such as any criminal record.
  1. Whilst this is our endeavor to keep you posted of the developments, we make no representations/warranties/commitment/undertaking of any kind, expressed or implied, about the commitment, completeness, accuracy, reliability, suitability or availability with respect to the Yatra. Any reliance you place on such information/intimation is therefore strictly at your own risk. In particular please keep in mind that the train schedule is approximate and subject to change
  1. In no event will we be liable for any loss or damage, indirect or consequential, arising from injury or death during the event. Applicants are advised to organizetheir own insurance policies for the duration of the journey.
  1. We are also not liable to loss of profits arising out of, or in connection with, the use of information/intimation from us/ our website.
  1. You are not allowed to join or leave JY midway unless there is a serious emergency.
  1. If for any personal reason you are to leave the JY mid-way you would have deprived another potential applicant the opportunity to travel on the journey and therefore you, will have to pay Rs 54,000/-. This amount may be moderated in exceptional personal circumstances by written agreement from the organizing team. Also please note that in such case applicant will not be issued a ‘Certificate of Participation ‘in JY.
  1. JY reserves the right to de-train any applicant during the journey for misconduct or misbehavior. This will be at the sole discretion of the organizing team, and any contribution deposited will not be refunded.
  1. The last to date for an applicant of JY 2015 to inform JY about their cancellation is 30th Nov 2015. In case of any cancellation, applicant should write to on or before 30th Nov 2015.

Refund Policy for Indian Nationals and *International candidates for JY 2015

  1. Membership contribution of Rs 5,000 ( 100 USD / 50 GBP) is non-refundable and will not be refunded in any case.

JSS will refund some or all of only the Yatra contribution paid in advance provided timely formal notice is given.

  1. Withdrawal/Refund

The last date to inform JY about withdrawal/cancellation and requestrefund is 30th Nov 2015.

Any cancellations or withdrawal after the 30th of Nov will not be eligible for refund.

  1. If applicant withdraws, on or before 30th Nov 2015, entire Yatra contribution is refundable.

The applicant must have a written communication via an email from JY on eligibility for refund.

To process the refund request, candidate will have to pay a processing fee of INR 7000/- .

All the refund claims will be settled by 15th March 2016, provided the refund processing fee has been deposited.

  1. Refunds in exceptional circumstances

Where an applicant gives a written notice of withdrawal after the deadline has passed due to the following exceptional circumstances JSS may, in its sole discretion, grant a total or partial refund of Yatri contribution. The organizing team may ask for an authentic document of proof in support of the exceptional situation. Exceptional circumstances include:

• Illness or disability or

• Death of the candidate or a close family member (parent, sibling, spouse or child) or

• A political, civil or natural event which prevents the candidate’s attendance; this decision is subject to the provision of acceptable documentary evidence in support of the application for a refund to the JY Office

  1. Deferral of Candidature

If after accepting an offer of a place, an applicant gives written notice on or before 31st Jan 2016 to defer the place to the next JY of 2016, all YatrI contribution will be transferred to the next Yatra.

JY is only permitted to approve a deferral on the grounds of circumstances mentioned above in point (4)

A place may be deferred for up to 12 months. If, after deferring, the applicant gives written notice of intention to not take up a deferred place, 50% of the Yatri contribution paid is refundable.

Applicants who are not eligible for refund, can defer their selection for the next Yatra by paying the difference in the Yatri contribution and registration charges for JY 2016.

  1. No refunds
  • No refund will be given where an applicant cannot join the Yatra due to any circumstances and fails to inform the JY office before the dead line for the same.
  • No refund will be given where an applicant cannot join the Yatra due to a delay in obtaining their visa in case of *International Candidates
  • For fees paid In International currency No refund will be processed in any International currency, either in GBP or USD. Refund for fees paid in international currency will be done in INR and only into any Indian Bank account. The amount refunded will be 54,000 INR only.

I have read the rules, regulations and refund policy and agree with the terms described.

Name - ______

Signature - ______

Date - ______

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