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APPLICATION FORM (FOR Ph.D. STUDENTS)

AUGUST / JANUARY SESSION

size photograph (4cm * 5cm) duly attested

Signature of the Applicant

Personal Details

Full Name: _________________________________________________________________________________________ Correspondence Address: ______________________________________________________________________________ Number and Street _________________________________________________ State Country Pin Code City Phone __________________________ With Area Code

Email Address _____________________________________________Mobile _________________________________________

Date of Birth
D D M M Y Y

Gender
M F

Marital Status
Single Married

Religion: _______________________

Nationality___________________________ Mother tongue _____________________

Category
Fulltime Parttime

1.Full time student with Fellowship / Assistantship 2. Full time student with External Fellowship 3. Full time student without Fellowship 4. I2IT faculty 5. I2IT regular employee (non-teaching) 6. Project scholar / staff of I2IT 7. QIP Scholar 8. Sponsored student 9. Local sponsored student (Part time)

Academic

a. Ph.D. Discipline (Write the name of the Discipline)

b. Whether you already have an M.Phil Yes If yes then specify area/ field:

No

c. Teaching/ Research/ Professional/ Industry Experience i. Area/ field: ii. Name of the Institute/ Organization:

Research Guide

1. Whether faculty guide at I2IT contacted? - Yes

No

2. If yes, then has the guide accepted? Yes

No

3. If yes, please mention the name of the guide _________________________________________________________

Sponsorship / Scholarship

a. Whether received/ will receive any scholarship Yes

No

b. If yes, then specify details of institution/ agency with full address, contact details:

Educational Qualification

Examinations

Degree Awarded

Specialization

University

Year

% Marks / Grades / CGPA or Equivalent

Graduation Postgraduation Any other qualification

Qualifying Score

Give details:
GATE _________________ NET _________________ Any other qualifying score (Please specify) _________________

Employment (Current Employment Only)

a. Designation: b. Occupation / Profession: c. Period fo Employment from ______________________ to ______________________ d. Name of the Organization: e. Address: f. Telephone: g. Email: h. Contact Person with Designation:

Record of past study as a sponsored candidate, or other contractual obligation, if any :

Synopsis Payment Details

Please write a synopsis in 150 - 200 words. (Attach an extra sheet of paper) 1. D.D. No._____________ Date:___________________ Bank: _________________________________________ _____________________________________________ 2. Details of Cash paid (Only at I2IT) Receipt No: ________________________________ Date: ___________________________

Application Fee

In case you have not paid the application fees, kindly mail a Demand Draft for Rs. 1,500/- drawn in favor of International Institute of Information Technology payable at Pune with the name and address of the candidate on the reverse. Send the completed application form to Student Relations Cell of the Institute at the given address. For those who have already paid the application form fees, please send the form along with photocopies of the documents. There is no relaxation in academic requirement for SC / ST / OBC / Handicapped students. I affirm that all of the above statements are true and correct to the best of my knowledge. I understand any false or misleading statement may constitute grounds for denial of admission or later expulsion.

Signed ______________________________________ Enclosures (Please send only attested photocopies)

MARK SHEETS (OF ALL EXAMINATIONS) QUALIFYING EXAM SCORE SHEET PASSPORT COPY (IF APPLICABLE) 2 RECOMMENDATIONS DULY FILLED AND SIGNED RECOMMENDATION FORM RELIEVING CERTIFICATE CO-SUPERVISOR FORM

Date____________________
WORK EXPERIENCE (IF ANY) ADDITIONAL CERTIFICATIONS (IF ANY) CASTE CERTIFICATE (IF APPLICABLE) SYNOPSIS SPONSORSHIP FORM CERTIFICATE FROM EMPLOYEE ORGANISATION

FOR OFFICE USE ONLY Registration number of the Applicant : __________/_____________ _________________________ Recommendation of Departmental Academic Committee Director / Dean Research The candidate may be called for interview. The candidate is not suitable for admission to Ph.D Program of the Department (Give reason). Does not satisfy short listing criteria. Others (specify) Head of the Department

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY P-14, MIDC, Phase-1, Rajiv Gandhi Infotech Park, Hinjewadi, Pune 411 057, India. Tel: +91 20 2293 3441 Telefax: +91 20 2293 4592 Mobile: +91 98226 17898, +91 98226 17899, +91 98604 65990 Toll Free No: 1800 233 4499 / 1800 233 6372 / 1800 200 2725 admissions@isquareit.ac.in | www.isquareit.ac.in
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Jan-11