N NA AT TI IO ON NA AL L I IN NS ST TI IT TU UT TE E O OF F T TE EC CH HN NO OL LO OG GY Y K KA AR RN NA AT TA AK KA A, , S SU UR RA AT TH HK KA AL L

P.O. SRINIVASNAGAR, MANGALORE-575 025

Registration No.
(for office use only)
Admission to Ph.D. Programme 2014-15 (Odd Semester)

Area of Specialization __________________________________________________________________________

Name of the Dept. _____________________________________________________________________________






Instructions:


1. Fill in the application form and the index sheet completely.

2. Fill your address in the address slips & Registration Memo.
3. Enclose self attested xerox copies of marks card and other documents.
4. Candidates who have appeared for the Final degree Examination of May /
June 2014 may also apply provided they can produce proof of their eligibility
for admission by September 15, 2014.
5. Late/incomplete/Applications without DD are liable to be rejected.

6. Last date for submission of filled in application is 16.06.2014

1. Name of the Candidate in full (in Block Letters
as mentioned in the Degree Mark Card):


2. Address of the applicant (with pin code):






a. Permanent:





b. Correspondence




c. Telephone with STD Code or
Mobile No. :

d. Email :
3. Name and address of Father/Mother (or Guardian
if the parents are not alive, state relationship of
Guardian)






4. Occupation of Father/Mother/Guardian
Annual Income





Affix self attested recent
Passport size photograph

Particulars of D.D. drawn
Name of the issuing Bank ________________________________
Drawn at _____________________________________________
D.D. No. ____________________ dated ____________________
Rs. _____________ Category: OC / SC / ST / OBC / PWD
(Tick mark the appropriate)


5. a. Religion of the Candidate:. .
Caste/Subcaste .

b. Do you belong to Scheduled Caste/Tribe/OBC(Tick mark) Yes / No SC / ST / OBC
If yes, enclose a copy of the Caste Certificate issued from
Competent Authority

c. Place of domicile

d. Nationality

e. Do you belong to Persons with Disabilities (PWD) group? Yes / No
(if yes, enclose copy of a medical certificate from a DMO)


6. Date of Birth (Copy of the Supporting document to be enclosed)
In Figures:
In Words:

7. Academic Record:
a) Post graduate Degree:

i. Examination Passed : M.E./M.Tech./M.Sc./MBA/MA/CA
/if any other specify (Attach all marks card copies)

ii. Specialization :

iii. Institute where he/she studied :
iv. Period of study : from __________________ to ________________
v. University :
vi. Marks obtained in the Qualifying Examination (Masters Degree):
(Attach all the marks card copies)


Year of
Passing
Marks/Grade
obtained
Max.
Marks
Percentage

Class/
Division

CGPA
I Year
I Sem
II Sem
II Year
III Sem
IV Sem
vii. Aggregate percentage of marks (all semesters/years) / CGPA :









b) Under graduate Degree:

i. Examination Passed : B.Tech/BE/B.Sc (Engg)/B.Sc/BA/AMIE/B.Com/
/if any other specify (Attach all marks card copies)

ii. Specialization :

iii. Institute where he/she studied :


iv. Period of study : from __________________ to ________________
v. University :
vi. Marks obtained in the Qualifying Examination:
(Attach all the marks card copies)


Year of
Passing
Marks/Grade
obtained
Max.
Marks
Percentage

Class/
Division

CGPA
I Year
I Sem
II Sem
II Year
III Sem
IV Sem
III Year I Sem
II Sem
IV Year III Sem
IV Sem

vii. Aggregate percentage of marks (all semesters/years) / CGPA :

8. Details of Practical Training under gone, if any, other than that required for graduate Course. Attach extra
sheet if necessary.
9. Professional/research or other Experience (Enclose Copies of Certificates from Employer)

Employer Post Held/Nature of Job Period Salary












10. Are you a Sponsored candidate?

(If yes, forward your application through your employer)





11. DECLARATION OF CANDIDATE

I hereby declare that to the best of my knowledge, the particulars furnished in this application are correct.

I am willing to forfeit the seat secured for any course, if any information provided by me is false.

If selected for admission, I promise to abide by the conditions of admission and Rules of the Institute, and the
Academic Regulations that govern the programme of study/ research. I also promise to refund the entire Fellowship
amount drawn by me in case I discontinue the Programme at any stage before completion.

Place :
Date : Signature of candidate



12. DECLARATION OF PARENT OR GUARDIAN

(Not applicable to candidates deputed on full salary by Institutions/ Industries)


In case my son/daughter/ward discontinues the course at any stage before completion without obtaining
permission from the Director and without repaying the fellowship amount drawn by him/her, I hereby undertake to
repay the Fellowship amount payable by my son/daughter/ward to the Institute.



Place:

Date : Signature of Parent or Guardian with Postal Address


In case declaration is signed by Guardian, Name
indicate relationship with the candidate Relationship

Self attested xerox copy of the following documents is to be enclosed.
1. Copy of the Marks Card of undergraduate and postgraduate Exam (all years/all semesters)
2. S.S.L.C./ X Std. Marks Card (for date of birth).
3. Caste Certificate issued by Competent authority for SC/ST
4. Persons with Disabilities (PWD) Certificate, if applicable.
5. Sponsorship letter for deputed candidates.
6. OBC Certificate in the Central Govt. format issued by competent authority in case of OBC.



















13. FOR USE BY FORWARDING AUTHORITY (EMPLOYER)

Sponsorship (Deputation) Certificate/
No objection certificate


The applicant (name) .has been a permanent staff of
this Institute/Organization from .. and has .. years of experience
(teaching/R&D/industry).
(a) Sponsorship/(Deputation) certificate:
He/She is sponsored (deputed) with full/half/no salary, for full time study/research in National Institute of
Technology Karnataka, Surathkal.

(b) No Objection Certificate:
He/She is permitted to undergo Part-time study/research in National Institute of Technology Karnataka, Surathkal
while continuing regular employment in the Institute/Organization.

The candidate and his/her sponsorship (deputation)/ NOC will not be withdrawn before the completion of the
course/programme.


Official Seal


Station: Signature of the Employer


Date : Name:


Designation:


(Note: Sponsorship certificate should be submitted in the same format as indicated in this application form
duly signed by the Employer/ Sponsoring Institute Head and seal.)














N.I.T.K. SURATHKAL, SRINIVASNAGAR, MANGALORE 575 025
INDEX SHEET Ph.D.
(READ INSTRUCTIONS OVERLEAF BEFORE FILLING)


1. Full Name :


2. Student Category: Full time / External Registrant/Internal Registrant


3. Qualification :


4. Details of Post graduate Degree:

a. Year of Passing qualifying exam (M.Tech./M.Sc./other)

b. Name of University :

c. Name of the Institution :

d. Have you obtained your final semester/ year marks sheet :

e. Aggregate of Percentage of marks (all semesters/years) of qualifying degree/CGPA

5. Details of under graduate Degree :

a. Year of passing undergraduate Degree (B.Tech / BE/ B.Sc./Other)

b. Name of University :

c. Name of Institution :

d. Aggregate percentage of marks (all semesters / years) or CGPA.

6. Reservation Category Code :



7. Experience (in years)



All the above information are correct to the best of my knowledge.


Signature of the applicant

M.Tech. M.Sc. Other



Teaching Research Field/Industry






YES NO

OC SC ST PWD OBC









NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA
SURATHKAL, POST SRINIVASNAGAR, MANGALORE- 575025,
KARNATAKA STATE.

REGISTRATION MEMO.
Date:......... 2014

Ref: Application for admission to Ph.D. Programme

The Registration No. assigned to your application for admission is noted below, which must be
quoted in all correspondences connected with your application. No notice will be taken of any
communication or document sent by you unless it bears your Registration Number.

Registration Number:




Ph.D. ......../2014-2015 Asst. Registrar (Academic)







To:

The Asst. Registrar (Academic), Mr./Ms. _______________________
N.I.T.K., Surathkal _______________________________
Post Srinivasnagar ________________________________
MANGALORE - 575 025. _______________________________



Affix
Stamp
Rs.6/-



(Write address of the candidate)

To To:
_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

Pin Code ________ (__________ State) Pin Code ___________ (________State)






To To:
_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

Pin Code _________ (__________State) Pin Code __________(__________State)














































APPLICATION FOR BY REGISTERED POST
ADMISSION 2014
Ph.D. Programme
________________________________


From: To:

____________________________ The Asst. Registrar (Academic),
____________________________ N.I.T.K., Surathkal
____________________________ Post Srinivasnagar
____________________________ MANGALORE - 575 025.
____________________________