application form12

7/27/2019 Application Form12

1/3

ORM

INDIAN INSTITUTE OF TECHNOLOGY KANPURAPPLICATION F $ FOR ADMISSION TO POST-GRADUATE PROGRAMME

(For filling this application form see instructions overleaf)

1. Full Name :

Paste your

photograph

here

2. Date of Birth : . Place of Birth : . Sex: Male/Female

5. Marital Status: 6. Nationality :

7. Fathers Name :

8. Address of Correspondence :

State: Pin Code :

9. If available, please provide:

Phone No. : Mobile No. :

E-mail address :

10. Details of Demand Draft

CodesforItems11-16aregivenoverleaf

11. Department/Programme

12. Admission for Degree

13. Category

14. Student Status

15. Financial Status

16. Physically Handicapped

a) Amount Rs . .. No. .... Date .

b) Issued by (Bank Name & Branch) ......

17. Academic Record/Work Experience

A. GATE, CSIR, UGC, other fellowship exam details (*)

Exam Name Exam discipline GATE Score/CSIR/UGC Rank Exam Year

B. Qualifying Degree (*) already obtained or in progress

Institute/ College

(Name & Address)

University

(Name & Address)

Discipline Degree Exam Date Finalresults

expectedby

PassMarks %or GradeAverage

Sem. I Sem. II Sem. III Sem. IV

Sem. V Sem. VI Sem. VII Sem. VIII

% Marks or

Grade AverageOverall % or

Grade Average

(if degree completed)

C. Other Degrees (*) obtained after 10+2 (Do not include the degree listed in 17 B)

Institute/ College

(Name & Address)

University

(Name & Address)

Discipline Degree Marks orCPI

Date ofcompletion


2/3

D. Working Experience (**)

Dates (from-to) Employer Position Nature of Work

E. Number of Technical Papers: Published in Journals Presented in Conferences

Providedetailsseparately

(*) Attach attested copies of certificates, mark sheet etc. See checklist overleaf for certificates required.

(**) A candidate presently working must provide a No Objection/Relieving certificate from the employer.

($) Photocopies of this form or copies downloaded from the IIT Kanpur website http://www.iitk.ac.in/doaa/admissions.html) are acceptable.

18. Areas of specialization in the Department/Programme (See Information Brochure)

Pref. 1 Pref. 2

Pref. 3 Pref. 4

19. Names and addresses of two referees from whom letters of reference have been obtained (For Ph.D. applicants only)

1. 2.

20. Declaration by the applicant:

Certified, that all information provided by me on this form is correct to the best of my knowledge and belief. I understand that anywilful misrepresentation of facts will result in my dismissal from the institute. If admitted, I shall abide by all the rules and regulations of the

institute.

Date : Signature :


3/3

IN S T R U C T I O N S F O R F I L L I N G T H I S F O R M

1. Either TYPE or PRINT the entries on the form neatly.

2. Go through the codes for Items 11-16 given below, a nd fill them carefully in the boxes on Page 1.

3. All items marked with an asterisk (*) require you to submit an attested copy of some document. PLEASE DO NOT SEND

ORIGINALS. Documents for which attested copies are required are given in the checklist. Please tick off the items in this

checklist you are attaching to this form.

4. The application fee of Rs. 200/- for candidates in General/OBC/PD and Rs. 100/- for SC/ST must be paid through demand draft

payable to The Registrar I I T Kanpurat Kanpur

CODES (FOR ITEMS 11-16)

Item 11: Department/Programme Codes: {A erospace Engg. = AE}, {Chemical Engg. = CHE}, {Civil Engg. = CE}, {Computer Science

& Engg. = CSE}, {Electrical Engg. = EE}, (Design Programme = DP), {Industrial & Management Engg. = IME} {Mechanical

Engg. = ME}, {Materials Science & Engg. = MSE} {Chemistry = CHM}, {Mathematics and Statistics = MTS}, {Physics =

PHY},{Humanities&SocialSciences=HSS},{LaserTechnology=LT}, {MaterialsScienceProgramme=MSP},{Nuclear

Engg. & Technology = N ET}, {Environmental Engg. & Management = EEM}, {Biological Sciences and Bio - Engineering =

BSBE}.

Item 12: MT = M.Tech., PH = Ph.D. , MD = M. Des.

Item 13: Category

SC*=Scheduled Caste (certificate required); ST*=Scheduled Tribe (certificate required); OBC*=Other Backward Class

(Certificate of Non-creamy layer required); GN=General; FN=Foreign Nationals;

Item 14: Student Status- Full Time = FT; Part-Time = PT, External = EXT

Item 15: Financial Status: Sponsored (*)= SD; Institute Assistantship requested= IA; Other = OTH

Item 16: Physically Handicapped= PH

CHECKLIST (CIRCLE THE ENCLOSED DOCUMENTS). SEND ONLY ATTESTED COPIES (NOT ORIGINALS).

1. Date of Birth (DOB) Certificate or High School (Class Te n) Certificate with DOB (Required for all candidates)

2. SC/ST/OBC Certificate if applicable (Item 13)

3. Certificate of Physical Status (Type of disab ility to be attached).

4. Sponsorship certificate for sponsored candidates. (Item 15)

5. GATE/CSIR/UGC score card (Item 17 A)

6. Copies of mark/grade sheets (Items 17 B & 17C)

7. No Objection/relieving Certificate from employer (for employed candidates)

8. The Demand draft for the application fee of Rs. 200/- or Rs. 100/- as applicable

9. Two letters of reference (for Ph.D. applicants only)

10. One self addressed envelope of 23cm x10cm.

The completed Application Form must reach on or before

April 16for admission in July Semester

Mailing Address for Submission of Applications:

The Convenor, DPGC

+

Department/Programme of (kindly mentioned the Department name where you are seeking your admission)

Indian Institute of Technology KanpurKanpur - 208 016 U.P.

+ Department Post-Graduate Committee.