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Application No :

INSTITUTE OF CHEMICAL TECHNOLOGY


(University Under Section -3 of UGC Act 1956)

N. M. Parekh Marg, Matunga, Mumbai 400 019 INDIA


Tel: 91-22-3361-1111/ 2222 Fax: 91223361-1020,
Email: admission@ictmumbai.edu.in; admission.ict@gmail.com
Website : www.ictmumbai.edu.in

Handbook No:

APPLICATION FORM FOR ADMISSION TO


Ph.D. (Tech.) / Ph.D. (Sci.)
Integrated Ph.D. (Tech.) (after B.Chem.Eng./B.Tech.)
Branch: _________________________ Dept.: ______________________
1. (a) Applicants name as per the format of Government of Maharashtra (In Block Letters)

____________________

_________________

_______________________

_________________

Surname/Family Name
First Name
Fathers/Husbands Name
Mothers name
(b) Name Appearing on supporting documents as School /Board/ Jr. College/University Certificates

Affix your
recent
coloured Photograph
Size - 45 x 35 mm

____________________________________________________________________________________

2. DATE OF BIRTH: _____


(dd)
3. (a) SEX : MALE

_____ _____ Place of Birth _________________ State __________________


(mm) (yyyy)

FEMALE

(b) MARITAL STATUS : Married

4. NATIONALITY _____________________________

Single

DOMICILE STATE __________________________

FOR OFFICE USE ONLY


5. ADDRESS FOR CORRESPONDENCE (In Block Letters):
________________________________________________________________________________________

________________________________________________________________________________________

Village/Town/City:- _________________ Taluka:- _________________District:- ______________________

State ___________________ PIN _____________________ Mobile No ____________________________

(Applicant shall not write


Anything in this space)

STD Code: ____________________________ Phone No (land line): _______________________________



6. PARENTS / GUARDIANS NAME & ADDRESS:
________________________________________________________________________________________

Whether admitted

________________________________________________________________________________________

YES

Village / City:- _________________ Taluka:- ___________________ District:- _______________________

NO

State ___________________ PIN _____________________ Mobile No ____________________________

STD Code: ____________________________ Phone No (land line): _______________________________

7. (a) Applicants E-Mail address: _____________________________________________________________


Provisional
Confirmed

(b) E-Mail address of Parent / Guardian: ______________________________________________________

Fellowship available

8. Religion : _______________________________________________________________________________

YES

9. Category (Please in appropriate box)

NO

Open

SC

FROM MAHARASHTRA STATE ONLY

ST

VJDT/NT-A

NT-B

NT-C

NT-D

OBC

Name of fellowship

SBC

_____________________

10. Details of the Qualifying Examination: (Give Details)



______________________
Month and Year of Passing

_____________
Seat No.

_________________
Marks % / CGPA

_______________
Class

College/Institution

: ____________________________________________________________________

University

: ____________________________________________________________________

Subject / Courses Studied : ____________________________________________________________________


GATE / GPAT / NET / SET / Other : _________________

Seat No.

_________________________
Month and Year of Passing.

___________
Score

_____________________
Receiving Date

_____________________
Receivers Signature

11. Proposed Area of Research and Name of Proposed Faculty Member of ICT as Research Supervisor
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________

Application No.

_____________________
Signature of Head of
the Department

Handbook No.________________

INSTITUTTE OF CHEMICAL TECHNOLOGY, (University under Section 3 of UGC Act 1956), MATUNGA, MUMBAI- 400 019.
Received an application for admission to Ph.D. (Tech.) / Integrated Ph.D. (Tech.) / Ph.D.(Sci.) Degree course from
Shri/Smt. ________________________________________________
Date __________________________

____________________________________
(Receivers Signature with Stamp)

NB : Please enclose a self addressed envelope (22 X 10 cm.) bearing Rs.5/- postal stamp for receiving the acknowledgement by post.

12. Family Data: - (Only Parents, Brothers & Sisters)


No.

Name of Family Member

Educational
qualification

Date of Birth

Current Occupation

Approx. Annual
Income, `

1
2
3
4
5
13. ACADEMIC RECORD:
Examination

Board / University

Month &
Year of
Passing

Total
Marks
Obtained

Maximum
Marks

%
Marks

Class /
CGPA

Name of College / Institute

SSC / Std. X or Equivalent


HSSC/Std. XII or Equivalent
B.Sc./B.E./B.Chem.Engg./
B.Tech. / B.Pharm. /
Equivalent
M.Sc./M.E./M.Chem.Engg./
M.Tech./M.Pharm. Part - I
Part - II or Thesis
GATE / GPAT /SET / NET / other (Attach attested copies of all the Statement of Marks)
14. Account for academic break, if any / (Please attach affidavit for the same) _________________________________________________
15. Academic /Industrial Experience, (if any) (Mention position held, period and Organization / Institute)
16. Documents to be attached: - Please Refer Handbook

DECLARATION
I have read the instructions given in the Handbook carefully before filling up this form. The information given above is true, complete and
correct to the best of my knowledge and belief. In the event of any information being found false or incorrect, my admission may be cancelled
without any notice. If admitted, I shall abide by all the rules, regulations and discipline of the Institute. I shall not involve myself in any ragging
or anti-social activities which will not only tarnish my own but also the institutes image and if I come to know any such incidence, I shall report
it to the authorities. I will also submit the undertaking regarding the anti-ragging measures, once admitted.

Place ________________________


Date ________________________

FOR OFFICE USE ONLY :
1.
Research Supervisors Comments

__________________________________
Signature of Applicant
3. Financial support to the Candidate

New student / Already guided

Fellowship agency _______________________

Guidance Available / not available

With / Without HRA ______________________

Research Scheme ________________________

Remarks _______________________________

Signature of Guide with Date _______________

2.

Current enrolment of research students

with the guide excluding this applicant is

Masters : ________

May be Admitted / May Not be Admitted, Date __________

Doctoral : ________

Fees Receipt No.______________ Date ________________

4. Remarks by office :


Approved / Not approved

____________________
AR (Academic)

Signature of Dean
(Academic Programme)

Please read very carefully all instructions given in the Handbook before
filling up this form and submit the completed form before the last date. Any
misrepresentation of records or over-writing on official documents will lead
rejection of the application form.