yd tanga Rorgeso ws tet htrece fares eee weet (A Govt. of India Enterprise and a subsidiary of ONGC Ltd.) Kuthethoor Post, Via Katipalla, Mangalore — 575030 MANGALORE REFINERY AND PETROCHEMICALS LTD. Reavest form for Internship at MRPL To be filed by the student and endorsed by Head of Department of College/ Principal of the College and Guardian of the student. Please fill in legible hand writing in copital letters. Do not leave any column blank. Please write ‘NA’ wherever itis not applicable. This application has 4 pages. Duly filed application has to be submitted at MIRPL Training Centre in original on or before the specified date. Submission of application does not automatically ensure permission for internship. Permission is subject to approval of the Competent Authority. A recent colour photograph of the student has to be pasted at appropriate place in the box. TRG/F/06 Poste your colour photograph here, Section | - Details of College/Institution 1 [Name of the College/ Institution 2 |Full Address of the College! Institution ‘with pin code and contact number Name of Head of Depariment/ Principal Contact number of Head of Depariment/ Principal Section Il - Details of Student 1 |Name of the Student 2 [Registration number of the student Gender| 3 |Name of the Guardian & Relationship 4 |Contact Number of Guardian Full Address of the student with Pin code ‘Aadhar Card No. 6 7 |Emait Mobile| 8 |CategoryiGen/SC/sT/O8C) 9 |Whether Person with Disability(Yes/No) [Section Ill - Details of study 1 [Name of the Course 2 [Duration of the Course (In Semesters/ Years, whichever applicable) _. Semesters) Years 3 [Branch of study Semester of study* 4 |Last completed semester for which results are declared 5 [Whether the student has cleared all papers fil last Yes /No completed semester for which results are declared = Bi'Semester and above for UG and 2" Year and above for PG only allowed for infemship. ‘MRPL- Application for Internship Training Page of 4‘Section IV ~ Details of internship isthe internship compulsory as part of the] Yes/No Curiculum 1 2 |Preferred month of internship June/ July/ December! January 3 |No. of days of intemship requested** ‘Kecidental Insurance Policy No.(Please attach self-attested copy of the policy] 4 5 [Period of validity of Insurance Policy “Maximum 15 days for UG and 8 weeks for PG. (i) Declaration by the student Thereby certify that all the details mentioned above from Section | to Section IV are true to the best of my knowledge and | am aware that if any of the details mentioned above are not correct, then it will lead to the rejection of my application for intemship. | have not undergone ‘any similar type of training at MRPL before. Name of the Student Signature with date (li) Declaration by Head of Department/Principal Ihereby certify that Q) The details mentioned above from Section | to Section IV are true and has been verified from the official records: wherever applicable. b) The internship requested 8 compulsory as part of the curriculum. ¢) The student has cleared all papers filllast completed semester for which results are declared, | will also be responsible for the conduct and discipline of the student during the internship training. The college also undertake to indemnify Mangalore Refinery and Petrochemicals Limited for ‘any loss or damage to equipment, machinery or fitfings etc. that may be caused by the above student during the internship training. Name& Designation Signature with date College Seal (li Declaration by the Guardian Tam aware that my son/daughter/ward, Mr./Ms. is applying for internship training at MRPL. He/she is covered with accidental insurance policy for coverage in the event of any untoward incident during the intemship training. | will ensure that he/she shal abide by the rules of MRPL during the period of intemship training. Name ofthe Guardian signature with date 'MRPL- Application for internship Training Page 2 oraDeclaration by ndergoing internshiptraini \ (name) student of (college name} is applying for intemship training at MRPL. [hereby declare that; 1. Iwill abide by all the rules and regulations of MRPL while inside the premises of MRPL, | will maintain discipline and follow safety rules of MRPL meticulously while inside the premises of RPL. | will solely be responsible for any accident happening to me due to violation of any safety rules. | will maintain a formal dress code while inside the premises of MRPL. | will wear Safety Shoes and Helmets wherever itis required to be worn as per the safety rules, While entering and leaving the refinery, ! will daily register my attendance at main security gate at 9:30 am in the morning and register my exit at 4:30 pm in the evening. | will also sign the attendance register maintained at Training Centre every day in the morning as well as in theevening, Iwon't access any Company documents unless | am authorised by MRPL personnel 8. Iwill not carry any Company documents outside unless | am authorised in writing by MRPL. 9. Lwill not damage any property of MRPL and willbe solely responsible to indemnify MRPL in case of any such damage because of me. 10. | will follow the instructions given by MRPL personnel diligently and will remain at specific work areos/ places allocated to me and | will not misbehave in any manner. 11, Lwillretum all the items provided to me by MRPL on completion of training (like Helmets, Punch cards etc] 12, Iwillnot be absent from training without the permission of authorised MRPL personnel, 13, [will ubmit o structured report after completion of my intemship training (| understand that the said report needs fo have space for sign of Guide/MRPL HOD and the report needs to have proper index and page number etc.) to MRPL Training Centre. | ako understand the issuance of intemship cerfificate from MRPL will be subject 10 submission of my report, complete in all respect, to MRPL Training Centre. 14, understand that | will have fo make a presentation to MRPL about my internship study in case it is required by MRPL. 15. | understand that permission to undergo intemship training does not guarantee internship cerfificate ‘andis subject to conditions, also understand that in case the report mentioned above is not satisfactory, MRPL will not issue the internship cerlficate to me. 16. Iwill not carry Mobile phone, Laptop, Pen drive inside MRPL premises. | will aso not bring my vehicle inside Refinery premises. 17. Lam aware that my internship training at MRPL is subject to fulfilment of above conditions and at any {ime if it is found that 1am not observing / fulfling any of the above conditions, my training will be terminated immediately and | willnot be eligible to obtain a certificate of completion of training. 18, labo hereby undertake to abide by all instructions given to me by MRPL Training Centre during the period of my internship training at MRPL. Name ofthe Student Signature with date ‘MPL. Application for Internship Training Page 2 of 4Detailsofretere jomMRPLEmployee 'hereby nominate the above mentioned student for internship training at MRPL as per the extant rules. Emp.No. Name Dept. Designation Intercom Mobile No. Name of Head of Dept. & Emp.No. Signature of the Employee with date ~ Signature of Head of the Department with date- Note: Documents to be attached: 1) Original request letter from the Institute 2) In case of SC/ST/OBC candidates, certificate copy 3) Self attested copy of Insurance Policy (Refer Section IV, S.No.4above) sseeseeesnanesseeress For Office Use (MRPL Training Centre) *ttstersseresenese Training Approved: Yes/No Remarks, if any: Applicationno. Name of the Guide: Designation: Department: Location: Date: Signature: 'MIRPL- Application for Intarnship Training Page 4 of 6