Indian Institute of Technology (Banaras Hindu University) : VARANASI - 221 005
Indian Institute of Technology (Banaras Hindu University) : VARANASI - 221 005
. / Ph.D. Programme
(See Instructions for filling this application form)
IV. Student Status V. Financial Status VI. Physically Challenged Codes for I-VI are given in Instructions.
1. Name of the Applicant: Mr./Ms. ..... (in Block Letters) 2. Fathers Name: .............................. (in Block Letters) 3. Mothers Name: (in Block Letters) 4. Sex: Male/Female 6. Nationality: 7. Date of Birth: D D M M 5. Marital Status: Married/Unmarried If foreign national, Passport No. Y Y 8. Place of Birth :...
9. Address for Correspondence:.. ..... Phone No. Mobile No. E-Mail ............................ 10. Permanent Address: ...... ..... Phone No. Mobile No. E-Mail ............................ 11. Application Fee : (Through online www.onlinesbi.com/prelogin/icollecthome.htm) Amount Rs. .. e-Receipt No. . Date . N.B. An amount of Rs.500/- for General/OBC/PC candidates or Rs. 250/- for SC/ST candidates per programme (M.Tech./M.Pharm./Ph.D.) should be paid. Photocopy of the e-Receipt must be attached with the Application Form. If the candidate is applying to more than one Department/School, he/she needs to pay the fee only once.
12. Details of Academic Record/Research Experience: A. Whether qualified GATE/GPAT/CSIR/UGC NET or any other fellowship exam --- YES/NO Exam Name Exam discipline GATE/GPAT Score and/or CSIR/UGC NET Rank Year
Note: For M.Tech./ M.Pharm programmes, a valid GATE/GPAT score is required. B. Qualifying degree (*) already obtained or in progress Institute/College (Name and Address) University (Name and Address) Final Results declared/ Expected by Pass Marks % or Grade Point Average
Discipline
Degree
Exam Date
Sem. I
Sem. II
Sem. III
Sem. IV
Sem. V
Sem. VI
Sem.VII
Sem. VIII
Sem. IX
Sem. X
C. Other qualifications : High school onwards (*) (Do not include the Degree listed in 12B) Institute/College (Name and Address) University (Name and Address) Discipline Degree % Marks or Grade Point Date of Completion
D. Working experience (**): Date (from to) Employer Position Nature of Work
** A candidate presently working in an organization must provide a Certificate from the employer as per Forms I, II, III & IV whichever is applicable or copy of his/her resignation letter submitted to the employer.
E.
Number of technical papers/books: (provide details separately) Published in Journals Published as Articles Published in Proceedings Published as Books
13. Department/School and specializations therein (in order of preference), which the candidate wants to join 1. Department/School .. Specialization (i) .. (ii).. (iii)..(iv). 2. Department/School .. Specialization (i) .. (ii).. (iii)..(iv). 3. Department/School .. Specialization (i) .. (ii).. (iii)..(iv). 4. Department/School .. Specialization (i) .. (ii).. (iii)..(iv).
14. Names and addresses of two referees from whom confidential letters of references have been obtained in sealed and signed envelopes by the candidate . (For Ph.D. applicants only) 1. .. 2. . . . ...................................................................... ...................................................................... ......................................................................
15. Declaration by the Applicant Certified that all the information provided by me on this form is correct to the best of my knowledge and belief. I understand that any willful misinterpretation 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: ..
Mailing Address for Submission of Application: The Convener, Department Postgraduate Committee (DPGC) Department / School of (mention the one where you are seeking admission) Indian Institute of Technology (BHU), Varanasi 221005, INDIA.
[Please submit original application along with the photocopy of the e-receipt of online payment to the Department/School which is your first preference and mail copies (up to and including Page 4 of this Form) along with the photocopy of the e-receipt of online payment to other preferred Departments/Schools]
IMPORTANT NOTES
1. The term ordinarily reside(s)** used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950. 2. Officers competent to issue Caste/Tribe certificates: (i) District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional Deputy Commissioner/Deputy Collector/1st Class Stipendiary Magistrate/City Magistrate/Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner. (ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate. (iii) Revenue Officers not below the rank of Tehsildar. (iv) Sub-Divisional Officer of the area where the candidate and/or his family normally reside(s). (v) Administrator/Secretary to Administrator/Development Officer (Lakshdweep Island). 3. Certificate issued by any other authority will be rejected.
Form I
Sponsorship Certificate for Sponsored Candidates (This should be typed on the letterhead of the sponsoring organization) Reference No:. Date: ... To The Director Indian Institute of Technology (BHU) Varanasi Subject: Sponsoring Our Employee as a Full Time Candidate for M.Tech./M.Pharm./Ph.D. Programme Dear Sir, We hereby sponsor Mr./Ms.. ......, son/daughter of
Shri & Smt. .. , who is a permanent employee in our organization, for joining M.Tech./M.Pharm./Ph.D. programme in the Department/School of .. at your Institute as a full-time student. It is certified that he/she has completed two years of service in our organization/Institute as a regular employee. He/she will be granted study leave for four/six semesters with full pay if admitted to the M.Tech./M.Pharm. or Ph.D. programmes. It is further certified that he/she will be taken back on his/her employment on the same post after the completion of his/her M.Tech./M.Pharm./Ph.D. programme and Form 16 will be issued to him/her during his/her study leave period every year.
Form II
No Objection Certificate for Part-Time Candidates (Project Staff of the Institute) (This should be provided by the concerned Principal Investigator of the Project) Reference No:. Date: ... To The Director Indian Institute of Technology (BHU) Varanasi Through: Head of the Department/Coordinator of School Subject: No-Objection Certificate Dear Sir, I have no objection if Mr./Ms ...., a project employee on the post of ... in the project ... working under me in the Department/School of ...., is admitted to the M.Tech./M.Pharm./Ph.D.
programme in the Department/School of .. . I agree to allow him/her to attend the classes and/or carry out his course and research work as are required under the rules and regulations governing the P.G. programmes of the Institute provided he/she will continue the work of the project for the entire duration of the project.
Forwarded by
Signature with date & seal of the Head of the Department/Coordinator of School
Form III No Objection Certificate for Part-Time Candidates (Permanent Staff of the Institute) (This should be typed on the letterhead of the concerned Head of the Department/Coordinator of School)
Reference No Date : To The Director Indian Institute of Technology (Banaras Hindu University) Varanasi
Subject : No objection certificate Dear Sir, I have no objection if Mr./Ms. ..... a permanent faculty of the Department/School of ..IIT (BHU) working as ., is admitted to the M.Tech./M.Pharm./Ph.D. programme in the Department/School of .. It is certified that he/she is a permanent employee of our department working since He/she will be allowed to attend classes and carry out research work as required under the rules and regulations governing P.G. programmes of the Institute. In addition he/she will also be doing his/her other assigned duties.
Signature with date & seal of the Head of the Department/Coordinator of School
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8. Details of relevant facilities which will be made available to the candidate: It is certified that the applicant has completed two years of service in our organization/institute as a regular employee. (a) If the applicant is admitted to the M.Tech./M.Pharm. programme, we agree to relieve him/her to be available at IIT (BHU), Varanasi for the minimum residency period required to complete the course work and also from time to time after that, for thesis evaluation examination and discussions with internal supervisor from IIT (BHU). (b) If the applicant is admitted to the Ph.D. programme, we agree to relieve him/her to enable him/her to stay on the campus of IIT (BHU), Varanasi to (i) complete the required course work, (ii) pass the comprehensive examination and to (iii) give the state-of-the-art seminar. He/she will also be permitted to visit IIT (BHU) from time to time for discussions with internal supervisor from IIT (BHU) as well as for evaluation of his progress during the course of his/her thesis work which he/she will be carrying out at our organization. The applicant will be permitted to carry out dissertation/thesis work under the guidance of the abovementioned local supervisor at our organization leading to the M.Tech./M.Pharm./Ph.D. degree. The necessary facilities with us will be provided for the purpose. We agree to relieve him/her with study leave for the above said period with full pay and we will take him/her back into service after the expiry of his/her leave. Signature, Name and Seal of the Sponsoring Authority 11
Form V
(Format of the Certificate to be submitted by the candidates who are unable to produce the final mark-sheet of the qualifying Examination at the time of written test/ interview)
CERTIFICATE
This certificate must be signed by the Principal/ Registrar/ Director of the Institution from which the candidate wrote his/her qualifying examination.
__ __
(B.Tech./B.Pharm./M.Tech./M.Pharm./B.S./M.Sc./M.A.)
in
(Discipline)
practical, Project, oral, etc.) in all subjects and has no back papers for any semester/year in which he/ she is yet to appear. He/She is only waiting for the results, which have not yet been declared by the University/ Institute.
(Signature and Name of the Signing Authority) Date : Position : Name of the Institution :
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Form VI
Undertaking by M.Tech./M.Pharm./Ph.D. Candidates who have been offered admission (to be submitted at the time of registration) Academic Year: ___________________ Semester: _______________________
I do hereby solemnly undertake to submit the following documents in the Academic Section on or before the Documents Submission Date as mentioned in the Academic Calendar of IIT (BHU) (about 8 weeks from the date of registration) on my admission to M.Tech./M.Pharm./Ph.D. programme. 1. Attested copy of the High School/Secondary School Examination indicating the date birth (being the only valid proof of age). 2. Attested copy of my final qualifying examination (B.Tech./B.Pharm./M.Tech./M.Pharm./B.S./M.Sc./M.A. certificate:
3. GATE Score with Admit Card/CSIR/UGC fellowship examination held on ________________ along with a copy. I also solemnly affirm that I have not used the score earlier for admission any where else and got admission. 4. Medical Certificate. In case of my failure in submitting any of the above documents on or before the specified date, I am aware that my admission shall automatically stand cancelled. Signature __________________________________ Full Name of the Student ______________________ ________________________________________ Programme _________________________________ Department _________________________________
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CONFIDENTIAL
Note to the Candidate: Candidate may give this form to a referee who can help us with his assessment of the candidates academic potential for Ph.D. The referee be requested to handover the sealed letter to the candidate. Name of the Applicant : ______________________________________________________________ Department/School to Which Admission Is Sought __________________________________________ Note for the Referee To help us in the appraisal of the candidates case for admission to a graduate programme at IIT (BHU), you are requested to fill in the following information to the best of your knowledge. This information will be treated as strictly confidential. 1. I have known the applicant for _________________ years. My knowledge of this student based on:
Having him/her in one or more courses Knowing him/her personally Supervision of his/her thesis/project Inquiry and discussion with my colleagues
2. Performance in my Courses: Course Title No. of Students Grade Remarks
3. The candidate ranks approximately ______ in a class of about ______ students. 4. My rating of the candidate in following traits: Excellent Analytical Ability Experimental Skills Motivation Written and Oral Expression Responsibility Teaching Ability Good Poor Unable to judge
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5. Any other remarks _________________________________________________________________________ 6. To summarize, I would say that the applicant:
is likely to become a brilliant scholar or an outstanding leader in his/her area of research is likely to do very well in the Ph. D. Programme is likely to perform satisfactorily in the Ph.D. Programme is not a good prospect for Ph.D. Programme 7. My recommendation : I recommend him/her without any reservations I recommend him/her I do not recommend him/her
Signature Date
_________________________________ __________________________________
_______________________________________________________________________________
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