Académique Documents
Professionnel Documents
Culture Documents
Handbook No:
____________________
_________________
_______________________
_________________
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
____________________________________________________________________________________
FEMALE
4. NATIONALITY _____________________________
Single
________________________________________________________________________________________
Whether admitted
________________________________________________________________________________________
YES
NO
Provisional
Confirmed
Fellowship available
8. Religion : _______________________________________________________________________________
YES
NO
Open
SC
ST
VJDT/NT-A
NT-B
NT-C
NT-D
OBC
Name of fellowship
SBC
_____________________
______________________
Month and Year of Passing
_____________
Seat No.
_________________
Marks % / CGPA
_______________
Class
College/Institution
: ____________________________________________________________________
University
: ____________________________________________________________________
_________________________
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.
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
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
Remarks _______________________________
2.
Masters : ________
Doctoral : ________
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.