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1.

2.

Name of the applicant ( in block letters)


Age as on 01.05.2016

3.
5.

Gender
Contact Details

Male
Telephone No.
Webmail

Female

Alt. Email ID
6.

Roll Number

7.

Latest CPI ( attach a copy of transcript)

8.

Details of Passport:
*(passport number and date of expiry, If applied provide
details)*
Person with disability:

10.

Semester

Course (B.Tech./ M.Tech. /


Ph.D./M.A./ M.Sc).: Ph.D

11.

Have you visited any foreign country for Internship,


Exchange, Conferences or any other Govt. of India
sponsored program? if Yes, provide details.

12.

Hobbies/ extracurricular activities/ area of interest:


(e.g.- membership in any student body/sports/cultural
activities etc. provide detail)
*(attach a copy of Certificate or supporting document)*

13.

Department: DESIGN

Yes

No

Kindly see the attached document

Languages known ( Indian/Foreign)

Language

Read

Write

Speak

Hindi
English
Bengali
Gujarati
14.
15.

Whether associated with any youth organization like NCC,


NSS, NYKS etc. (Others: Please specify)
*(attach a copy of Certificate or supporting document)*
Any achievement or awards in academics or
extracurricular activities *(attach a copy of Certificate or
supporting document)*

Signature of the applicant

Forwarding by HoD ( for all)