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Roll No:: (To Be Submitted Compulsory at Academic Office Through HOD/Convener of The Respective Academic Unit)

This document is a Joining Report/Declaration-Cum-Application form for students enrolling in a program at the Indian Institute of Technology Bombay. It collects personal details, academic records, work experience, and additional information, along with a declaration of adherence to institute rules. The form must be submitted to the Academic Office through the Head of Department or Convener of the respective Academic Unit.

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Kahnu Charana Das
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36 views2 pages

Roll No:: (To Be Submitted Compulsory at Academic Office Through HOD/Convener of The Respective Academic Unit)

This document is a Joining Report/Declaration-Cum-Application form for students enrolling in a program at the Indian Institute of Technology Bombay. It collects personal details, academic records, work experience, and additional information, along with a declaration of adherence to institute rules. The form must be submitted to the Academic Office through the Head of Department or Convener of the respective Academic Unit.

Uploaded by

Kahnu Charana Das
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Roll No :

INDIAN INSTITUTE OF TECHNOLOGY BOMBAY


Powai, Mumbai – 400 076

Joining Report/Declaration-Cum-Application form


for ________ Programme
(to be submitted compulsory at Academic Office through
HOD/Convener of the respective Academic Unit )

Department : _________________________ Specialisation : ________________________

A) Personal Details :

Name in English : __________________________________________________________________


Upload passport size
Name in Hindi : __________________________________________________________________ photograph in this space
( as in qualifying degree certificate)

Date of Birth : _______________ Place of Birth : _____________________ Sex : ___________

Nationality : __________Birth category : ___________ Person with Disability (Y/N) : __ EWS Y/N) : ___
(GN/GN-EWS/OBC-NC/SC/ST/PwD - attach xerox copy of certificate)

Married Status : _______________ Hostel No. _________ Room No. __________

Category ( TA/TAP/RA/RAP/SF/SW/PS/CSIR/FA... etc.) __________________________________

Date of Joining : ______________ (Registration & Signing the Attendance in the Department)

B) Communication Links :
Address of the candidate b) Name & Address of Parent/Guardian
for postal communication (i.e. Permanent Address) for postal communication
_______________________________________________ ___________________________________________________
_______________________________________________ ___________________________________________________
_______________________________________________ ___________________________________________________
City ___________________________________________ City _______________________________________________
State ___________________________Pin ____________ State _______________________Pin ____________________

Telephone Number (with STD code):


Mobile No*:
E-mail Address(s) :

C) Details of Academic Record (Secondary Onwards)


Examination Institute / University Passing Year % of marks/ CPI / Class / Division
CGPA (on the scale
of 10)

Contd.. on page.2..
-2-
Details of Qualifying Degree :
Qualifying Degree :______________________Name of University :_____________________________________

a) I have passed the Qualifying exam in the year ____________ in ____________ class with _________ %
Marks/CPI, Defence, Viva-voce held on _____________________.

b (i) I have appeared for the theory part of examination and yet to submit the dissertation.
(ii) I have passed the theory part of examination and have submitted the dissertation/home paper/
Project Report . The viva-voce/practical examination is yet to be held/likely date _______________.

GATE records : (Attach copy of GATE Score card )

Additional Qualification ( if any ) : ____________________________________________________________

D) Work Experience ( if any) :


No. of years of Experience : a) Teaching :________b) Industry:_______(attach experience certificate)

Name and Address of the Designation Job description Period Salary


Organization

E) Additional Information
Papers published, if any : No. of Papers : Published : ________ Under publication : _________( Please
attach extract)

F) DECLARATION
1. I reaffirm the declaration signed by me at the time of my seeking the admission to the
Institute to abide by the rules and accept the discipline in the Department.
2. I will not join any coercive agitation for the purpose of forcing the hands of the authority to
solve any problem.
3. I will not participate any activity, which has tendency to disturb the peace and the orderly life
of the campus.
4. I will co-operate with the Institute's authorities in maintaining discipline, academic standards
and good order in the campus.
5. I am totally aware that to posses and drive any motorized vehicle on the campus is prohibited
and I assure to adhere to.
6. I am aware about the rule that students joining under Teaching Assistantship (TA)/Research
Assistantship (RA)/ Project Research Assistantship (PA) category for any PG/Ph.D. Programme
of the Institute should not accept or hold any appointment paid or otherwise or receive any
emoluments, salary, stipend from any other source during the tenure of TA ship.
7. I am aware that Hostel accommodation on the campus strictly for the duration of the
programme.

Place: Date: Signature of the Applicant

Signature of Supervisor / Faculty Advisor : _____________________________________

Through HOD/Convener :_____________________________________________________

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