Admission to Ph. D. under PhD scheme of Deity in 2015-2016 are invited (full time/part time) in the association with Media Lab Asia, a company floated by Deity, Ministry of Communication and Information Technology, Govt. of India .
1. Application No. : _______________________________________
(To be filled by office)
2. Department Applied for: ___________________________________
3. Broad areas of (a) ______________________________________
specialization, the
candidate indents (b) _____________________________________
to work in the
Ph.D. Programme (c) ______________________________________
4. Full-Time/ Part Time (a) ________________________________
Ph.D Programme:
5. GATE or any other equivalent examination :
(a) Qualifying Year: ________________ (b) Exam Reg. No.:_________________
(c) Score:________________________ (d) All India Rank:_________________
(e) Paper with Code:_______________
6. Name:
(As in 10th Standard Grade Card)
____________________________________________
7. Father’s Name: ____________________________________________
8. Gender: Male: Female:
9. Date of Birth:
YYYY/MM/DD __________________________________
10. Category: Gen: OBC: SC: ST:
11. Physically Handicapped: Yes: No:
12. Marital Status: Single Married:
13. Contact details:
Address for correspondence Permanent Address
State: State:
Pin Code: Pin Code:
Mobile no: Phone No.:
Email Id: Alterative Email id:
NATIONAL INSTITUTE OF TECHNOLOGY PATNA
Ashok Raj Path, PATNA 800 005 (Bihar), India
Phone No.: 0612 – 2372715, 2370419, 2370843, 2371929, 2371930, 2371715 Fax – 0612- 2670631 Website: www. nitp.ac.in
14. Educational Qualification: (In reverse chronological order starting from qualifying exam till 10th class [attached the attested copies of the relevant certificates with marks card]
Degree/
Examination passed
Specialization University/
Institute
Year of passing
% of Marks or CGPA
Class/
Division
15. Work Experience: Teaching: ____________ Years __________ Months Industry: ____________ Years __________ Months
Organization Designation From To
[Attach the attested copies of the relevant experience certificates] (If required, use additional sheet)
16. List of Publication (if any) [Attach separate sheets if required]
(a)
(b)
(c)
17. Any other Achievements/Awards/Any other relevant information etc. [Attach separate sheets, if required]
18. Contact Details of two referees:
Referee 1 Referee II
Name:
Designation:
Organization:
Office Address:
Office Phone no.:
Mobile Number:
Email Id:
19. List of Enclosures:
1.
2.
3.
4.
5.
20. Payment details: DD. No.:
Bank:
Date:
Amount:
21. Declaration:
I do hereby solemnly declare that the information given above is correct to the best of my knowledge and belief. I am fully aware that I must produce the original certificates corresponding to the submitted attested copies of my qualifying degree certificates/ final transcripts or any of the documents submitted, failing which, my candidature will stand canceled. I am also aware that providing incorrect information in the application form and violation of norms of the Institute can result in the cancellation of my admission at any stage.
Place:
Date: Signature of the candidate with date
FOR USE BY FORWARDING AUTHORITY (EMPLOYER)
Sponsorship (Deputation) Certificate/ No objection Certificate
The applicant (name)……… has been a permanent staff of this Institute/Organization from ……….. and has …………. years of experience (teaching/R & D/ industry).
(a) Sponsorship / (Deputation) certificate:
He/ She is sponsored (deputed) with full/half/no salary, for full time study/ research in National Institute of Technology Patna.
(b) No Objection Certificate:
He/ She is permitted to undergo Part-time study/ research in National Institute of Technology Patna while continuing regular employment in the Institute/Organization.
The Candidate and his/ her sponsorship (deputation)/ NOC will not be withdrawn before the completion of the course/programme.
Official Seal
Station: Signature of the Employer
Date: Name:
Designation:
(Note: Sponsorship certificate should be submitted in the same format as indicated in this application form duly signed by the Employer/Sponsoring Institute Head and Seal)
