0 - 18 September, 2 0 - 26 September,

Dept. of Industrial & Systems Engineering , IIT Kharagpur. Email: jt@iem.iitkgp.ernet.in;

Leadership Skills Development Program LEAN SIX SIGMA at IIT Kharagpur

Date: ____________

S.No. Name of Participant Designation Total Experience Educational Degree Need Accommodation?

1.

2.

3.

4.

IIT Kharagpur (Industrial &Systems Engineering Department) and ASQ South Asia have developed a unique

offering to help individuals or organizations build capability in Lean and Six Sigma, which covers instruction,

learning, application and certification.

Individual Name/Company Name:

Home/ Office Address:

City:

State:

Pin Code:

Contact No:

E-mail id:

☐ Black Belt Training: INR 64,900 (55,000 + 18% GST)

Total No. of Participants: ………….

☐ Green Belt Training: INR 38,940 (33,000 + 18% GST)

Total No. of Participants: ………….

☐ Project Support (remote, 5 sessions *2 hours each)

INR47,200 ( 40,000 + 18% GST)

Total No. of Participants: …………

TOTAL: …INR………………………………………………

REGISTRATION FEES PAYMENT

INDIVIDUAL/PARTICIPANT INFORMATION

INDIVIDUAL/ORGANIZATION INFORMATION

PLEASE NOTE

Interested individual candidates

or organizations sponsoring

candidates may please send this

application along with

registration fees in the form of at

par cheque or DD in favour of :

“CEP-STC, IIT Kharagpur” payable

at Kharagpur, India.

Contact person: Dr. Jitesh

Thakkar Dept. of

Industrial & Systems Engineering

jt@iem.iitkgp.ernet.in

☐ Click this box, if the application is by an

individual, not sponsored by an organization

PLEASE NOTE

Interested individual candidates or organizations sponsoring candidates may please send this application along with registration fees in the form

of at par cheque or DD in advance, in favour of: “CEP-STC, IIT Kharagpur” payable at Kharagpur, India.

Registration fees may also be paid through wire transfer to: Authority holding the account: Dean, CE, IIT Kharagpur; Name of Account: CEP-STC; Bank Name: Syndicate Bank; Branch Name: SRIC, IIT Kharagpur 721302; Address: Dist. Paschim Medinipur, West Bengal; BRANCH MICR NO. 721025103; Account Type: SB; Account No. 95562200002955; IFSC Code: SYNB0009556; SWIFT Code: SYNBINBB120

Accommodation: Arrangements for single accommodation will be made at IITKGP Technology Guest House for those who need it. Approximate

expenses for boarding & lodging is Rs.2000 per day, to be directly paid to Guest House.

Contact Person IIT Kharagpur: Dr. Jitesh Thakkar

Dept. of Industrial & Systems Engineering, jt@iem.iitkgp.ernet.in, +91 3222 281830

Contact Person ASQ South Asia: Mr. B.S. Rawat

ASQ South Asia, 325 DLF Tower B, Jasola District Centre, New Delhi – 110025

asqindia@asq.org, +91 11 46783399

Individual/Authority Signature: ………….………