appln for phd program

8/13/2019 Appln for PhD Program

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NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA, SURATHKALNATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA, SURATHKALP.O. SRINIVASNAGAR, MANGALORE-575 025

Regis!"i#$ N#.

%! #&&i'e (se #$)*+

Aissi#$ # P./. P!#g!"e 201- %/e'e3e! Sessi#$+%U$e! e '"eg#!* F())-ie s(e$ 4i I$si(e S'#)"!si+

A!e" #& Se'i")i6"i#$ __________________________________________________________________________

N"e #& e /e. _____________________________________________________________________________

I$s!('i#$s

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

2. Fill your address in the address slips & Registration Memo.

3. Enclose attested photo copies of marks card and other documents.

. !ate"incomplete"#pplications $ithout %% are liale to e re'ected.

(. !ast date for sumission of filled in application is 25..201

1. )ame of the *andidate in full +in ,lock !etters

as mentioned in the %egree Mark *ard-

2. #ddress of the applicant +$ith pin code- a. /ermanent

. *orrespondence

c. 0elephone $ith 0% *ode or contact numer"

Moile )o.

d. email +if any-

3. )ame and address of Father"Mother +or uardian

if the parents are not alie4 state relationship of

uardian-

. 5ccupation of Father"Mother"uardian

#nnual 6ncome

#ffix self attested recent

/assport si7e photograph

P"!i'()"!s #& /./. !"4$

)ame of the issuing ,ank ________________________________

%ra$n at _____________________________________________

%.%. )o. ____________________ dated ____________________

Rs. _____________ *ategory 5* " * " 0 " 5,* " /*+0ick mark the appropriate-


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(. a. Religion of the *andidate. 88888888.

*aste"ucaste 88888888.

. %o you elong to cheduled *aste"0rie"5,*+0ick mark- 9es " )o * " 0 " 5,*

6f yes4 enclose a copy of the *aste *ertificate issued from

*ompetent #uthority

c. /lace of domicile

d. )ationality

e. %o you elong to /hysically :andicapped +/:-"/hysically *hallenged +/*- group; 9es " )o

+if yes4 enclose copy of a medical certificate from a %M5-

. #cademic Record

a. i. Examination /assed M.E."M.0ech."M.c."M,#"M#

any other +#ttach all marks card copy of degree certificate-

ii. pecialisation

iii. 6nstitute $here he"she studied

i. /eriod of study from __________________ to ________________

. ?niersity

. Marks otained in the @ualifying Examination +MasterAs %egree-

+#ttach copies of all marks cards-

Ye"! #&

P"ssi$g

M"!8s9G!"e

#3"i$e

M":.

M"!8s

Pe!'e$"geC)"ss9

/i;isi#$

CGPA

6 9ear6 em

66 em

66 9ear666 em

6B em


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C. .%etails of /ractical 0raining under gone4 if any4 other than that reDuired for graduate *ourse. #ttach extra sheet

if necessary.

. /rofessional"research or other Experience +Enclose *opies of *ertificates from Employer-

E)#*e! P#s He)9N"(!e #&


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1. /ECLARATION OF PARENT OR GUAR/IAN

+)ot applicale to candidates deputed on full salary y 6nstitutions" 6ndustries-

6n case my son"daughter"$ard discontinues the course at any stage efore completion $ithout otaining

permission from the %irector and $ithout repaying the fello$ship amount dra$n y him"her4 6 herey undertake to

repay the Fello$ship amount payale y my son"daughter"$ard to the 6nstitute.

/lace

%ate ignature of /arent or uardian $ith /ostal #ddress

6n case declaration is signed y uardian4 )ame

indicate relationship $ith the candidate Relationship

. FOR USE =Y FOR>AR/ING AUTHORITY %EMPLOYER+

S#$s#!si %/e("i#$+ Ce!i&i'"e9

N# #3?e'i#$ 'e!i&i'"e

0he applicant +name- 8888888888888888888888888.has een a permanent staff of

this 6nstitute"5rgani7ation from 888888.. and has 88888.. years of experience

+teaching"R&%"industry-.

+a- S#$s#!si9%/e("i#$+ 'e!i&i'"e

:e"he is sponsored +deputed- $ith full"half"no salary4 for full time study"research in )ational 6nstitute of

0echnology Harnataka4 urathkal.

0he candidate and his"her sponsorship +deputation-" )5* $ill not e $ithdra$n efore the completion of the

course"programme.

5fficial eal

tation ignature of the Employer

%ate )ame

%esignation

%N#e S#$s#!si 'e!i&i'"e s#() 3e s(3ie i$ e s"e !" "s i$i'"e i$ is ")i'"i#$ !

()* sig$e 3* e E)#*e!9 S#$s#!i$g I$si(e He" "$ se").+


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N.I.T.K. SURATHKAL, SRINIVASNAGAR, MANGALORE @ 575 025

IN/E SHEET @ P./.%REA/ INSTRUCTIONS OVERLEAF =EFORE FILLING+

1. Full )ame

2. tudent *ategory Full time

3. @ualification

. 9ear of /assing Dualifying exam +M.0ech."M.c."other-

(. )ame of ?niersity

. #ggregate of /ercentage of marks +all semesters"years- of Dualifying degree

C. Reseration *ategory *ode

. Experience +in years-

#ll the aoe information are correct to the est of my kno$ledge.

ignature of the applicant

M.Te'. M.S'. Oe!

5* * 0 /* 5,*

Te"'i$g Rese"!' Fie)9I$(s!*


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NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKASURATHKAL, POST SRINIVASNAGAR, MANGALORE- 575025,

KARNATAKA STATE.

REGISTRATION MEMO.%ate......... 213

Ref #pplication for admission to /h.%. /rogramme

0he Registration )o. assigned to your application for admission is noted elo$4 $hich must e Duoted in allcorrespondences connected $ith your application. )o notice $ill e taken of any communication or document sent y you

unless it ears your Registration )umer.

Registration )umer

/h.%. 88........"213I21 %y. Registrar +#cademic-

0o

Te /*. Regis!"! %A'"ei'+, Mr."Ms. _______________________

N.I.T.K., S(!"8") BBB ____________________________

P#s S!i$i;"s$"g"! ________________________________

MANGALORE - 575 025. _______________________________

#ffix

tampRs.


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%>!ie "!ess #& e '"$i"e+

0o 0o

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

/in *ode ________ +__________ tate- /in *ode ___________ +________tate-

0o 0o

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

_____________________________ _____________________________

/in *ode _________ +__________tate- /in *ode __________+__________tate-


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APPLICATION FOR =Y REGISTERE/ POST

A/MISSION 201

P./. P!#g!"e %/e'e3e! Sessi#$+

BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

From: 0o

____________________________ Te /*. Regis!"! %A'"ei'+,

____________________________ N.I.T.K., S(!"8")

____________________________ P#s S!i$i;"s$"g"!

____________________________ MANGALORE - 575 025.

____________________________

appln for phd program

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