भारतीय �ौयो�गक� सं�थान पटना Indian Institute of Technology Patna

For Office Use: Sl. No.: IITP/ACAD/PhD/2012/01/_____________

For Dept. Use: App. No.:_______________________________

(Fill the details of the Demand Draft drawn in favour of “IIT Patna” Payable at “Patna” for the Application Fee) Amount: Rs.

Draft No.:

Dated:

Drawn in Bank:

1. Full Name of the Applicant:

Affix your Recent

Passport size Photograph

2. Father’s/ Guardian’s/Spouse’s Name: 3. Date of Birth (dd-mm-yyyy): 4. Nationality:

5. Gender: 6. Marital Status:

7. Category: General / OBC (including OBC Minorities) (Non-Creamy Layer) / SC / ST (In case of SC/ ST/ OBC (Non-Creamy Layer), enclose the attested copy of certificate for the proof of category)

8. Are you a Person with Disability (PD)? Yes / No (If yes, enclose the attested copy of certificate from Govt. Medical Practitioner stating the type and percentage of physical disability)

9 (a). Contact Address: 9(b). Permanent Address:

9(c). Contact Phone Number: (In case of landline, write STD code also. Your Mobile phone number is preferable)

9(d). Contact Email Address:

10. Department at which the candidate seeks Ph.D. admission is: 11. Are you also applying for Ph.D. to any other Department at IIT Patna? Yes / No If yes, list the names of other departments:

(Candidates applying for more than one department should submit a separate application for each department)

12. Seeking Ph.D. admission under the category: (Strike out whichever is NOT applicable)

Regular & Full-Time / Sponsored ( Full-Time) / Employed & Part-Time / Project Staff

Part Time is permitted only to professionally employed person, who can attend the regular classes as per schedule of the Institute and carry out research while

employed for which his/her employer will give the leave of absence without any objection.

13. Choices for Area of Research for Ph.D. (See: Detailed Advertisement available on the website), in order of preference 1st Pref: 2nd Pref:

3rd Pref: 4th Pref:

14. Details of Academic Record (Attach attested copies of certificates, mark sheets, etc) Qualifying Degree already obtained or in progress: Degree Discipline Name & Place of Institution/ University Year of

Passing Final Results expected by

Minimum Passing % of Marks or Grade Average for the award of degree

Overall Percentage of Marks obtained or Final Grade Average*

Semester Sem - I Sem – II / Year - I Sem - III Sem – IV / Year- II Sem - V Sem – VI / Year - III

Percentage of Marks or Grade Average Obtained

Semester Sem - VII Sem –VIII / Year - IV Sem - IX Sem – X / Year - V Percentage of Marks or Grade Average Obtained

* If degree is not obtained, write the percentage of marks obtained or final Grade Average up to the pre-final semester/ year. Write the details of the academic record of 10th, 12th classes and the Degrees obtained other than Qualifying Degree mentioned above.

Degree/ Examination

Name of Institution/ Exam Board Year of Passing

Percentage of Marks/ Final

Grade Average

Class/ Division

Obtained

Subjects Taken

10th Class

12th Class

(other degree)

15. Professional examination (GATE/ UGC or CSIR NET/ NBHM/DBT-JRF/ other fellowship exams) passed:

Exam Name Exam Discipline Exam Score & Rank

Exam Passing Year

Valid upto

16. Professional Experience, if any. (Attach attested copy of the proof).

Name of Organization Position held Nature/ Type of Work Period (From – To)

A candidate presently working (including those on projects) and applying for Ph.D. admission under the category sponsored/ Institute Project Staff, must provide a “No Objection Certificate” from the employer and/ or “Sponsorship Letter” from the sponsoring agency.

17. List of Publications/ Projects, if any. (Attach a separate sheet with details, if necessary. No of Papers published in Refereed Journals: ______, No. of Papers presented in Refereed Conferences:____

18. List of Enclosures

Declaration I hereby declare that the entries made in this application form are correct to the best of my knowledge and belief. If selected for admission, I promise to abide by the rules and regulations of the Institute. The Institute shall have the right to take any action it deems fit, including expulsion, against me at any time after my admission, if it is found that any information furnished by me is incorrect. I note that the decision of the Institute is final in regard to selection for admission and assignment to a particular department and field of study. Place: Date: Signature of the Applicant

Please note: For complete details (Areas of Research, etc) on Ph.D. admission, visit the website: http://www.iitp.ac.in. Application Fee of Rs. 300/- (for Gen/OBC candidates) and Rs.150/- (for ST/SC/PD candidates) must be sent with this application by a demand draft drawn in favour of “Indian Institute of Technology Patna” and payable at Patna. The completed application enclosed with the demand draft for application fee and attested copies of mark sheets/certificates and with other necessary enclosures (if applicable) should be sent to the Assistant Registrar(Academic), Indian Institute of Technology Patna, Patliputra Colony, Patna – 800 013, Bihar, to reach on or before 30-04-2012. The words “Application for PhD admission in the Department of ______” should be written on the top of the envelope for sending the completed form.

Form I Sponsorship Letter

(This should be typed on the letter head of the sponsoring organization) Reference No.

Date: To, The Director Indian Institute of Technology Patna

Sub: Sponsoring an Employee for PhD Programme Dear Sir, We hereby sponsor the candidature of Mr./Ms./Mrs. ________________________________ who is an employee in our organization, for joining PhD programme in ____________________________ at your Institute as a full-time student. We shall relieve him/her from his/her duties in the organization during the first three years of the PhD programme.

Signature and Seal of the Sponsoring Authority

Form II No-Objection Certificate for IIT Patna’s Project Staff (This should be typed on the letterhead of the R&D Section of IIT Patna)

Reference No.

Date: To, The Director Indian Institute of Technology Patna

Sub: No-Objection Certificate for IIT Patna’s Project Staff Dear Sir, The R&D Section, of IIT Patna, has no objection if Mr./Ms./Mrs. ___________________________ a project employee in the project _________________________________________________ under ___________________________________________department, is admitted to the PhD programme in _____________________________. Principal Investigator of the concerned project has agreed to allow him/her to attend classes/research work during the PhD programme.

Signature and Seal of the Coordinator Sponsored Research, IIT Patna

Form III

No-Objection Certificate for Part-Time Students (This should be typed on the letter head of the sponsoring organization)

Reference No.

Date: To, The Director Indian Institute of Technology Patna

Sub: No-Objection Certificate Dear Sir, We have no objection if Mr./Ms./Mrs. ________________________________________ an employee in our organization, is admitted to the PhD programme in _____________________________ at your Institute as a PART-TIME student. It is certified that he/she has completed 1(one) year of service in our organization/institute as a regular employee. We shall grant him/her leave of absence to attend classes/research works at IIT Patna during

the PhD programme.

Signature and Seal of the Sponsoring Authority

ANNEXURE-I

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT TO POSTS / ADMISSION TO CENTRAL EDUCATIONAL INSTITUTIONS (CEIs), UNDER THE

GOVERNMENT OF INDIA

This is to certify that Shri/Smt./Kum. _____________________________ Son/Daughter of Shri/Smt.

__________________________________ of Village/Town ________________________________ District/Division

__________________________ in the _________________________ State belongs to the

________________________ Community which is recognized as a backward class under:

(i) Resolution No. 12011/68/93-BCC(C) dated 10/09/93 published in the Gazette of

India Extraordinary Part I Section I No. 186 dated 13/09/93. (ii) Resolution No. 12011/9/94-BCC dated 19/10/94 published in the Gazette of India

Extraordinary Part I Section I No. 163 dated 20/10/94. (iii) Resolution No. 12011/7/95-BCC dated 24/05/95 published in the Gazette of India

Extraordinary Part I Section I No. 88 dated 25/05/95. (iv) Resolution No. 12011/96/94-BCC dated 9/03/96. (v) Resolution No. 12011/44/96-BCC dated 6/12/96 published in the Gazette of India

Extraordinary Part I Section I No. 210 dated 11/12/96. (vi) Resolution No. 12011/13/97-BCC dated 03/12/97. (vii) Resolution No. 12011/99/94-BCC dated 11/12/97. (viii) Resolution No. 12011/68/98-BCC dated 27/10/99. (ix) Resolution No. 12011/88/98-BCC dated 6/12/99 published in the Gazette of India

Extraordinary Part I Section I No. 270 dated 06/12/99. (x) Resolution No. 12011/36/99-BCC dated 04/04/2000 published in the Gazette of India

Extraordinary Part I Section I No. 71 dated 04/04/2000. (xi) Resolution No. 12011/44/99-BCC dated 21/09/2000 published in the Gazette of India

Extraordinary Part I Section I No. 210 dated 21/09/2000. (xii) Resolution No. 12015/9/2000-BCC dated 06/09/2001. (xiii) Resolution No. 12011/1/2001-BCC dated 19/06/2003. (xiv) Resolution No. 12011/4/2002-BCC dated 13/01/2004. (xv) Resolution No. 12011/9/2004-BCC dated 16/01/2006 published in the Gazette of

India Extraordinary Part I Section I No. 210 dated 16/01/2006. Shri/Smt./Kum. ________________________________ and/or his family ordinarily reside(s) in the

__________________________ District/Division of ______________________State. This is also to certify that

he/she does not belong to the persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the

Government of India, Department of Personnel & Training O.M. No. 36012/22/93-Estt.(SCT) dated 08/09/93

which is modified vide OM No. 36033/3/2004 Estt.(Res.) dated 09/03/2004.

Dated:

District Magistrate/

Deputy Commissioner, etc. Seal

Page - 7

NOTE:

(a) The term ‘Ordinarily’ used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.

(b) The authorities competent to issue Caste Certificates are indicated below: (i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional Deputy

Commissioner / Deputy Collector / Ist Class Stipendiary Magistrate / Sub-Divisional magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank of Ist Class Stipendiary Magistrate).

(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.

(iii) Revenue Officer not below the rank of Tehsildar’ and (iv) Sub-Divisional Officer of the area where the candidate and / or his family resides.

ANNEXURE-II

Declaration/undertaking - for OBC Candidates only

I, __________________________ son/daughter of Shri ______________________ resident of village/town/city

____________ district _________________ State hereby declare that I belong to the _______________ community

which is recognized as a backward class by the Government of India for the purpose of reservation in services as per

orders contained in Department of Personnel and Training Office Memorandum No.36012/22/93- Estt. (SCT), dated

8/9/1993. It is also declared that I do not belong to persons/sections (Creamy Layer) mentioned in Column 3 of the

Schedule to the above referred Office Memorandum, dated 8/9/1993, which is modified vide Department of Personnel and

Training Office Memorandum No.36033/3/2004 Estt.(Res.) dated 9/3/2004.

Signature of the Candidate Place: Date: Declaration/undertaking not signed by Candidate will be rejected.

Page - 8

Annexure- III

DECLARATION / UNDERTAKING – BY OBC(NCL) - MINORITY CATEGORY CANDIDATES ONLY

I, ________________________________ son / daughter of Shri _________________________________ resident of________________________ village/town/city __________________________________ district ________________________ State _______________hereby declare that I belong to OBC(NCL) – MINORITY Category as notified by Central Government of India. I also declare that the condition of status / annual income for ‘Creamy Layer’ of my parents is within prescribed limits as on financial year ending on March 31, 2012. Based on this declaration I request you to kindly consider me as OBC(NCL) – minority. I will submit the attested copy of the certificate at the time of registration for the course. Signature of the Candidate Roll No. Place: Date: Signature of the Parent/Guardian (Declaration / undertaking not signed by candidate and countersigned by parents will be rejected) Place: Date:

Page - 9

DATA SHEET FOR THE APPLICANT (NAME): ……………………………………….. DEPARTMENT OF: …………………………………………….

App. No. (For

Office Use)

Name & Address Category Point 7

Application form

Topics of interest Descending by preference

Academic Qualifications Experiences (For

employed Candidates)

Remarks (For Official

Use) Degree % of marks

Year in which

Completed

Name:

X

Mailing Address:

XII

Date of Birth

DD/MM/YYYY

B.E./ B.Tech/ B.Sc./ B.A.

PIN Code:

Gate score and validity

M.E./ M.Tech./ M.Sc./ M.A.

Phone and Mobile Number:

M.Phil.

Email ID:

Category in Which Applied: Point 12 – Application form