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Office Use

ANNA UNIVERSITY OF TECHNOLOGY, COIMBATORE


Jothipuram, Coimbatore 641 047.

Application Form for Admission to Ph.D./M.Tech.(By Research) Programme-January 2011


CENTRE FOR RESEARCH
Programme :
(TICK APPROPRIATE)

Ph.D
[ [ [ [ ] ] ] ]

M.Tech.(By Research) Photo


Full Time Internal Full Time External Part Time Internal Part Time External [ [ [ [ ] ] ]

Full Time Internal (Refer Instructions Full Time External to the candidates) Part Time Internal Part Time External

Faculty Code With Name (Ref. Annexure 1)

1. 2. 3. 4. 5. 6. 7. 8. 9.

Name of the Candidate


[BLOCK Letters]

: : : : : : : : : : : : : : : OC / BC / MBC / SC / SCA / ST / Others Married / UnMarried Male / Female

Father / Guardian Name Designation & Department Gender Age (Attach Proof) Date of Birth Marital Status Nationality Religion

10. Community (Attach Proof) 11. Name of the Caste 12. Office Address ( Ref. Annexure 2) College Code College Name College Address & Phone no

13. Residential Address

14. Phone No 15. Mobile No 16. Email ID

: : :

17. Academic Qualification (UG, PG & Others) Name of the Institution Degree

University

Year of Completion

Specialization

Marks

Class / Rank

18. Experience Details Organization Designation From To

19. Tentative Research Title 20. Abstract of the Proposed Research topic ( to be Enclosed)

21. Whether he / she has been awarded fellowship like UGC,CSIR,etc. If so, give details : 22. Awards, Medals, Prizes and Honours achieved in his / her career :

23.

Any other particulars he/she would like to present for the consideration of the authorities.

24. Whether he /she has already registered or discontinued the Ph.D. /M.Sc. (Engineering) M.Tech (By Research) Programme etc. in any other institution. If so, give details 25. Whether he /she any publications/ articles to his /her credit. If so, give details (Attached a Separate Sheet,if necessary)

26.

Name & Address of the Institution, where the proposed research supervisor is located ( Attach Proof) Supervisor ID Number * Name of the Supervisor Office Address E-mail id Number of the Candidates currently registered under him /her with this / any other University. If with other universities, mention the name of the Universities

27.

: Application Fees/SBI Power Jyothi Challan details(Attach University copy - Original ) Branch Name Branch Code Amount Date Journal No

28. ATTACHMENTS (TICK APPROPRIATE) SSLC +2 / Diploma UG Degree Certificate PG Degree Certificate M.Phil. Degree Certificate NOC from Head of the Institution Where employed Service Certificate Acceptance of the Research Supervisor Community Certificate Challan Enclose attested Xerox copy Declaration

[ [ [ [ [ [ [ [ [ [

] ] ] ] ] ] ] ] ] ]

The above particulars given by me are correct to the best of my knowledge .. Place: Signature of the Applicant Date : --------------------------------------------------------------------------------------------------------------------------------------------------------------(Office use only) Verified by Staff (Name) Eligible / Not Eligible Signature

Mandatory field

ANNA UNIVERSITY OF TECHNOLOGY,COIMBATORE Coimbatore -641 047. To be filled in by the Supervisor concerned Particulars required with regards to the candidates of Ph.D., / M.Tech.(By Research) Degree currently registered under the Supervision of ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Name of the Candidates ----------------------------------------------------------------------------------------------------(Note : Candidates who have been permitted recently to register Ph.D. degree should also be indicated)
Whether Stipendiary or Non Stipendiary if Stipendiary, mention the Source

Sl.No

Name of the Candidates

Whether Full Time or Partime

When Registered

When likely to complete the Minimum Period

1 2 3 4 5 6 7 8 9 10 11 12

Note : The number of candidates registered under your guidance should not exceed twelve. Whether the Supervisor is recognized if so, state the No. and date of this University communication through which he /she is recognized as a Supervisor for Ph.D. / M.Tech.(By Research) Programme.

Supervisor ID Number. -------------------------------- Date.---------------------Name of the Proposed Supervisor


(Designation with Complete Official Address)

Signature

Contact No.

Seal

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