eoNDufANJl uNIVEg,snY, e.*.DcHIgoIJ
(Established by Government of Maharashtra Notification No. MISC -2007t(322tOU UNl4
Dated2Th Sept. 2011 Staie University Governed by Maharashtra University Act, 1994 )
NAT:ONAL SERVICE SCHEME
Dr.l.S. Mohurley
Programme Coordinator
Mobilet
777
4027 661, 9422893555
MIDC Road, Complex,GADCHlROL|- 442 605 (M.S)
web: qondwana.diqitaluniversitv.acl
Email
:
A
onlz-zztlzz
director.studentwelfarequs@qmail-com
Fat t}7t32-223322
Avhan-2015/44 Date:
The Principal of conceming colleges
Affi liated to Gondwana University, Gadchiroli.
Subject:- Selection ofNSS Volunteers for Avhan: the disaster management training camp-2015.
Respected Sir,
As per the directions by the Secretary to the Govemor, the AYHAN State Level Disaster
Management Training Camp has been decided to be given to the NSS volunteers in Maharashtra. For
Academic yeat 2014-15 the Training camp of AVIIAN will be organized at Shreemati Nathibai
Damodar Thakarsi Womin University Mumbai between 256 May, 20lS & 3.d June 2015. The
travelling expenses to attend this training camp will be provided from Disaster Management funds of
Univenity. Railway Reservation of all the students and team leaders from Nagpur to Mumbai and
Mumbai to Nagpur is already done. Every student and team leader must haye to reach al Nagpur
Railway Station before 2.00 pm positively on 23 May 2015.
Every participant as a volunteers or program Officer must bring following items/articles with
them while attending the training camp, such as two sets of white Pants and full shirts, Spoon, Bed
sheet, Battery, Note Book, Pen, Shoes (Any one of Hunter/Canvas/Sports). They must bring College
Identity card, Enrolment form duly signed, certified documents with then.
The NSS volunteers/ the Programme officer from your college selected as per the attached list to
participate in the said training camp. You are kindly requested to send the required certificates to the NSS
Office sharply on or before 20 May 2015 and make the necessary arrangements.
Thanking yoq
Regards
Gondwana University, Gadchiroli
Enclosures:
I
)
2)
List of volunteers Gadchiroli District and Chandrapur District
Necessary Certificates to fill and send to Univelsity Programme Coordinator NSS for uploading
the data of participants online.
GONDW.*Nfi. UNIVf,.BSITY, GJIDCHIROLI
LIST OF CON丁 :NGENttFOR AVHAN‐ 2015
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Contingent Leaders
:
Gadchiro‖
1)prOf.Saniav M Mahalan(9049757160)
2)Prof.5mt Lokhande(9420511560}
LIST OF FEMALE CONT:NGENT
Name of Volu nteers
Adarsh
Kumud Bangare
Ada rsh College, Wadsa
Resh
ma Suresh
Sh rad
ha Waman
Kove
Vaishali loghenttam
ina f r.rnt-ota rirtuyyu
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kka surayya
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M. G.
Co
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M. G.
Co
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BhaBwantrao Arts ColleBe,
Sironcha
BhaBwa ntrao Arts College,
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Rina Sudhakar Tekam
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WAITING LiST OF FEMALE CONTINGENT
● ０
Ｓ Ｎ
Name of Volunteers
1
Dipa Mangesh
Weladi
2
Paya I Karme
Komal Kamble
(n
College Address
5. B. Co llege, Aheri
Bhagwantrao College,
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Minal Vitthalrao
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I Dipak Vishweshwar
Parteke
Milind Honaji
Pradhan
Krishi Mahavidya laya,
Gadchiroli
G. M.College, Kurkheda
Rajesh Chinnamma
Bhagwantrao Arts College,
Siro ncha
Mahindra Pochelu
18
9
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Kunal Keshav
6urnule
Homkant Falgun Raut
10
Pankaj Nago
hasaokar
Ashutosh Narayan
166
I Agril‖
Bhagwantrao Arts College,
Sironcha
M. G. College, Armori
82/78
B Sc l1
171
94/89
8412907648
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AVHAN― CHANCELLOR BRIGADE TRAINING PROGRAM ON DI〔
PREPAREDNESS
REGISTRAT10N FORM AND COMMITMENT CERTIFICATES PERSONAL
INFORMAT10N
Name:
Class― ――――――――――――――
Div― ―――――――――
Roll
Residential Address-----.---Taluka― ―
―――――
―― ―
District
Pin Code― ―――……
―
Contact dctail STD Code― ―――
――
――Rcsidence Teト ー
ーーーーMObile
Emaill D
―
―
―
―
―
―
―
Datc ofBirth― ――
――
Age― ……………―
Spectacles:Ycs/
Hei
ght-:=-----Wei ght-------Blood Group---
PARENTSINFORMAT10N
--Hbyo-- --------- - - - - -- - -
ー
Name:
Office Address-―
――………Taluka― ――――――_Distict
Pin Codc――――――………―
Contact detail STD Code― ―………―
――Residcncc Tel― ―¨― Mobilc― ―
EmaiH D
NSTITUTIONAL INFORNIAT10N
Name OF College:
onEcial Addrcss
―
―
―
―
―
―
―
― ―
―
―
―
―――
Taluka― ―
――____District― ―
――
―――Pin Codc―
Contact detail STD COde
Tel― ――――__― ――― Fax
_____
No― ―……―
Emaill D
Name
of
Residcntial Addrcss― ――――――――……………――――――――――――――――………
――――――
Taluka― ―――____― ―DistHct― ―――――――Pin
Code_________¨
Contact dctail STD Code― ――………―Tel― ―――――――
― MObilc No― ――_― ―――
‐
Ema‖ ID― ――――¨―――――
―――
Name of Program
Rcsidential Address
Contact detail STD Codc ――
――――¨― Tcl― ―――――___― Mobile No一 ―__― ――
EmalH D
Name of University:
OIIice Address-Contact dctail STD Code― ―
‐
――
―_― ―Tel― ―
――
――
―………―
Fax No
Emaill D
沈 STER
Name of Program
Residential Address
―
………―― Tel― ――――――――Moblc
Contact detal STD Codc― ―
No
Emaill D
Other Information
Enrollment Year ofNSS:
Skills known:
DH宙 T
MIIImmg l COOkng
下
戸
gra"y 「 kponWiJng E"nghthg
而
Wish to particiPate
Swimming
will
l di宙 ng
Any Other
Fire Fighting
First Aid training
like to know Procedure in police statior/Legal knowledge
Anv other additional information:
1)COMⅣ
ΠT｀ CNT
CERTIFICATES
(Jointly Singc NSS Voluntcer/Parents/Programmcr offlcer&Ceni″
by Prindpal)
UNDERTAKING BY THE PARTICIPATING STUDENT
A)
at -------I undertake to state that I shall be attending the training program ofAVHAN to be held
V
In consideration ofmy being nominated at my request to undergo all t)'pes of training and also
participating in any NSS training activities in/outside NSS and traveling. I undertake and agree
that
neither
I
nor
my
executor/administrator
will
make
any claim against
any officer
of
NSS/Principal /Program Coordinator/State Liaison Officer/ Youth Officer/Assistant Program
Adviser/Deputy Program adviser in respect of any loss or injury to the property or person
(including injury resulting in death.) which may suffer while or inconsequence of my being in
training/participating in AVHAN
I further undertake to state that I shall be abiding by all rules & regulation ofthe
camp and shall be liable for strict disciplinary action for violation ofthe same=
Signature of the Student
Date:
B)
I
RESPONSIBILITY CERTIFICATE
agree as
a
responsible person that
my Son/DaughterAMard is being allowed
to
participate in the above mentioned
camp to be held at ___-_- University
at my own risk.
Ifany accident or death occurs during
this camp/program, I or any ofmy
relation of
legal heir will not demand any claim
from State Govt./ University/College
an account
Si
ofmy Son/Daughter /Ward being
NSS uni!
a part this camp.
gnature of the parent/Guardian
Date:
C) VOLUNTEERSHIP CERTIFICATE
It is certificate that the vorunteer is a
confide
student
he/she is a regular NSS Volunteer
from
one year
of
of the coregernstitution
and
the year _-_-____-_and has completed
his/her
volunteer ship and he/she is neither
a member ofNCC nor a member
of
Scouts and Guides/Rovers/Rangers.
Signature of NSS program
Officer
Signature of the principal
College Seal
2)
CERTIFIcATE oF MEDIcAL/PHYSIcAL FITNESs
Signature of the candidate:
I do hereby certiry that I have
examined the vorunteer and
found him,rer fit for undergoing
rigorous training for AVHAN_
sisnature given
above,.,",
.,#l?.u"ff:Iffi,",:'""r1T.,fr"il:,:,:",
may cause any hindrance due
to
training program.
Signarure of the Medical Officer
Address with Contact No
3)
VERIFICATION CERTIFICATE
This is to certifr that
Mr/JvIs__-__-
_-___
;::;
his/her participation in the
above mentioned rigorous
Seal
Date---------_-_--_____- NSS
Volunteers
of
_--_______-
College is a bonafide student
and NSS Volunteers of___-_--____---__
--------------University. The information
provided in the registration
form by the vorunteer
and a' the certificates signed
by him/her. parents program
officer, hincipar and medicar
Officer are endorsed by me
as a program Coordinator
ofthe University.
Signature of the program
Coordinator
University
Seal
Date:
_--
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