Ministry of Science and Technology Department of Science and Technology

WOMEN SCIENTISTS SCHEME (WOS-A) Research in Basic/Applied Sciences

SUBJECT CODE: Please specify Subject Code (I-VII) :

Physical Sciences Chemical Sciences Mathematical Sciences Life Sciences Earth Sciences Atmospheric Sciences Engineering Sciences I II III IV V VI VII

BREAK IN CAREER: YES / NO

DECLARATION BY THE CANDIDATE

I have gone through the fellowship rules and conditions of the award and if selected, I agree to abide by them. The particulars given in the form are correct and I am prepared to present myself for presentation/discussion, if called upon to do so.

Date:

Signature of the Candidate

SECTION A GENERAL INFORMATION

1. 2. 3. 4. 5. 6. 7. Name (in Block Letters) Husband/Fathers name Postal address for correspondence E-mail (mandatory) Permanent address Date of Birth Whether belong to SC/ST/OBC/PH (Attach copy of the relevant certificate) 8. 9. Married/Unmarried : : : : : : : :

Academic record (from matriculation onwards): Degree Period of Study From - To Board/University/ Institute Subject Marks (%)

Sl.No.

10. 11. 12. 13. 14. 15. 16. 17. 18.

Scholarships, Medals, Fellowships, Awards, Distinctions or Honors received during your University/academic career Whether passed examinations conducted by NET/GATE/UGC/ICAR, etc. If yes, indicate the name of the examination, year and grade Professional/employment record (if any, in chronological order) Provide details of demonstrable dissertations, patents, etc.) research experience (e.g. publications,

Title of Ph.D. thesis and name of Supervisor Details of break in career after highest qualification, if any (gap period in years with reasons for break) Name three (3) institutions and scientists in the country who are working in the proposed area of research Are you getting or availed fellowship/scholarship through any other scheme. If yes, please provide details Any other relevant information

SECTION B DETAILS OF THE R&D PROJECT

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Title of the Project Broad subject area (as given in Subject Code) Area of specialization Total cost of the project Summary of the proposal (not exceeding 500 words) Objectives National and international status Methodology Work plan Expected deliverables/outcome Significance of the expected outcome with respect to the state-of-the-art in the field Name, address of the institution and bio-data of the scientist-mentor (including last 5 years publications in cited journals) with whom the proposed R&D study will be executed. Facilities in terms of laboratory, equipment, etc. likely to be made available to the candidate by the host institution for pursuing the above studies Details of financial requirements (with justification) for the duration of the project (3 years) and year-wise phasing Head Research fellowship Consumables Travel (within India) Contingencies Equipments (generic name) Overhead charges GRAND TOTAL 1st Year 2nd Year 3rd Year Total

13. 14.

S.No. 1. 2. 3. 4. 5. 6. 7. 15. 16.

Justification for the budgetary requirement item wise based on the scientific needs of the project Details of research funding received or applied for (mention reference no., title, duration, cost, funding agency and brief achievements)

Incomplete application in any respect liable to be rejected