Nomination Form

Youth Immersion Programme for
Entrepreneurs’ of Uttar Pradesh

Name of the Entrepreneur *

First

Last

Date of Establishment

Email ID *

Mobile Number *

Residence Location

Address Line 1

City

State / Province / Region

Postal Code

Country

Date of Birth

Registered Name of Startup

Registered for Location

Address Line 1

City

State / Province / Region

Postal Code

Country

Revenue

Business Type : Technology

Yes
No

Team Size

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Name *

Email *

Phone Number *

Select State *

Select City *

Select Campus Preference *

I authorize Jaipuria Institute of Management to contact me with updates & notification via Email, SMS & WhatsApp. This will override registry on DNC/NDNC.*