Category : GM SC ST CAT-I Physically Challenged Others

Male Female
Name: ......ate o! "irth:....
Father#s Name:..
Academic Qualification:
Programme egree
o$tained
%ni&ersity 'eg(lar )
istance
S*eciali+ation , Mar-s o$tained
.ith Class
/ear o!
*assing
%G
PG
Others i! any

No. o! years o! e0*erience: Ind(stry: Teaching: 'esearch:
N(m$er o! 'esearch *a*ers: Patents: A.ards:
Topic of Research proposed:




Research Centre
1. 2T%-'C: .e*artment:....'ecogni+ed: /es No

3. 2T%-'4: e*artment:.....'ecogni+ed: /es No
5. 2T%-''C: Belgaum. e*artment...
A**lication and Processing Fee etails: .. !or `. 677)- No.:ra.n on "an-...date:.
Applicants Address for correspondence

VISVESVARAYA TECH!"!#ICA" $IVERSITY%

BE"#A$&% 'ARATA'A
A(("ICATI! )!R& )!R (H*+ &,Sc, -Engg. BY RESEARCH
)!R THE ACA*E&IC YEAR /012314



'esearch Centre a**lied !or: 2T%-'C 2T%-'4 2T%-''C

Fac(lty A**lied !or : 8ngineering Architect(re Science Management St(dies
F(ll time Part time Programme A**lied !or: Ph.. M.Sc.98ngg:

.
Paste 9 do not *in :
*ass*ort si+e
*hotogra*h in this
s*ace and get it
attested $y Princi*al
) ;ead o! College )
%ni&ersity last
attended or a
Ga+etted O!!icer
.

.
(5one+Cell o.. email6id: ..
Information of the Supervisor
Name: ate o! "irth...
A!!iliation : e*artment:
esignationArea o! 'esearch
Academic Qualification:
Programme egree
o$tained
%ni&ersity 'eg(lar )
istance
S*eciali+ation , Mar-s o$tained
.ith Class
/ear o!
*assing
%G
PG
Ph..
Others i! any
o, of (u7lications in t5e preceding 4 8ears:
Research papers: 1. National <o(rnal communicated: 1. National <o(rnal
3. International <o(rnal 1. 3. International <o(rnal
Conference: Technical Reports: Book: Patents: Awards:
No. of students Supervising:
Sl,
o,
Name o! the
Candidate)s
Programme
Please tic- 9:
%ni&ersity Category
/ear o!
registration
S*eci!y
.hether acting
as S(*er&isor
or
Co S(*er&isor
Area o!
S*eciali+ation
=hether
Final Thesis
S($mitted
9/)N:
Ph.. M.Sc.
98ngg:
1
3
5
>
?
@
A
6
Total
Undertaking from the Supervisor
IB is a *ermanent !ac(lty )em*loyee .or-ing as . in the
e*artment o! . in the organisation .......and is aged
less than @3 years as on the date o! admission noti!icationB here$y certi!y that the candidate Mr.)Mrs...
.registering !or ..... degree (nder 2T% is not my son)da(ghter)immediate $lood relati&e and the total n(m$er o!
candidates registered (nder me in 2T% and other %ni&ersities !or $oth Ph.. 4 M.Sc. 98ngg.: $y 'esearch ta-en together e0cl(ding *resently
a**lied candidates is 9in =ords: The in!ormation *ro&ided a$o&e is tr(e to the $est o! my -no.ledge.
*ate:
(lace:
Signature : 66666666666666666666666666666666666666666
)or9arded 78 B...

*ate: Signature of t5e (rincipal+*irector+Head of t5e Researc5 Centre 9it5 Seal
Information of the Co-Supervisor( if applicale!
Name: .ate o! "irth...
A!!iliation: . .. e*artment:
esignationArea o! 'esearch
Academic Qualification:
Programme egree
o$tained
%ni&ersity 'eg(lar )
istance
S*eciali+ation , Mar-s o$tained
.ith Class
/ear o!
*assing
%G
PG
Ph..
Others i! any
o, of (u7lications in t5e preceding 4 8ears:
Research papers: 1. National <o(rnal communicated: 1. National <o(rnal
3. International <o(rnal 1. 3. International <o(rnal
Conference: Technical Reports: Book: Patents: Awards:
No. of students Supervising:

Sl,
o,
Name o! the
Candidate)s
Programme
Please tic- 9:
%ni&ersity Category
/ear o!
registration
S*eci!y
.hether
acting as
S(*er&isor or
Co S(*er&isor
Area o!
S*eciali+ation
=hether
Final
Thesis
S($mitted
9/)N:
Ph.. M.Sc.
98ngg:
1
3
5
>
?
@
A
6
Total
Undertaking from the Co-Supervisor
IB is a *ermanent !ac(lty )em*loyee .or-ing as . in the
e*artment o! . in the organisation .......and is aged
less than @? years as on the date o! admission noti!ication here$y certi!y that the candidate Mr.)Mrs...
.registering !or ..... degree (nder 2T% is not my son)da(ghter)immediate $lood relati&e and the total n(m$er o!
candidates registered (nder me in 2T% and other %ni&ersities !or $oth Ph.. 4 M.Sc. 98ngg.: $y 'esearch ta-en together e0cl(ding *resently
a**lied candidates is 9in =ords:. The in!ormation *ro&ided a$o&e is tr(e to the $est o! my -no.ledge.
*ate:
(lace:
Signature : 66666666666666666666666666666666666666666
)or9arded 78 B...

*ate: Signature of t5e (rincipal+*irector+Head of t5e Researc5 Centre 9it5 Seal
$nderta:ing 78 Super;isor + Co3Super;isor <-in case Co3Super;isor is opted.
o !7=ection Certificate of t5e !rganisation
Emplo8ment Certificate of t5e Super;isor
Emplo8ment Certificate of t5e Co3Super;isor -in case Co3Super;isor is opted.
I ) =e ha&e no o$Cection in g(iding the said candidate in the *ro*osed area o! research at the designated 'esearch Centre.
I! !or any reasonB mysel! )candidate change the 'esearch CentreB I ).e .ill in!orm the same to the %ni&ersity .itho(t
!ail.
Signature of Co3Supervisor Signature of t5e Supervisor
Signature of t5e Head of t5e Institution 95ere t5e researc5 9or: is proposed:>>>>>>>>>>>>>>>,>>

This is to certi!y that the Organisation has no o$Cection in recommending the candidat(re o! o(r
em*loyee!or carrying o(t research !or his)her Ph..) M.Sc. 98ngg.: $y research
at .... on *art
time ) !(ll time $asis. T5e information pro;ided 78 t5e candidate is found correct as per our records.
Signature of t5e (rincipal+Head 9it5 Seal,
This is to certi!y that r. *resently .or-ing in the ca*acity
o!in the e*artment o!... is a full time emplo8ee o!
o(r OrganisationB since..
Organisation: Seal and Signat(re o! the
;ead o! the Organisation
This is to certi!y that r *resently .or-ing in the ca*acity
o!in the e*artment o!... is a full time emplo8ee o!
o(r OrganisationB since..
Organisation: .. Seal and Signat(re o! the
;ead o! the Organisation
Super;isors Address for correspondence
Co3Super;isors Address for correspondence
.
.

.
.

"nclose attested copies of the follo#ing$ efore sending the application :
1. Detailed Bio-data of the Candidate, Supervisor
(and Co-Supervisor, if applicable)
6. Any other additional Certificates supporting your claim
for benefits like
!edical Certificate for the degree of disability in
support of candidates claiming benefit
"est Score Card along #ith Admission ticket in
support of clearance of $%C&$%C-CS'( )(*
'n case candidate&Supervisors are possessing
degree from *oreign $niversities, "he +,uivalence
Certificate issued by the Association of 'ndian
$niversities( A'$)
-assport #ith .isa in the case of *oreign candidates
3. $% and -% degree Certificates and !arks cards of the
Candidate
5. $%, -% and -hD Degree Certificates of the
Supervisor&Co-supervisor
>. Category certificate of candidates belonging to SC&S"&Cat-
'& and any other if applicable
?. Synopsis of the proposed research
@. Syllabus of the Course #ork chosen for the present study
A.
Demand Draft of `/011 dra#n in favour of "he *inance
2fficer, ."$, Belgaum to#ards Application and -rocessing
fee
(5,*,+&,Sc,-Engg.

Name o! the A**licant:
Name o! the S(*er&isor : .....
Name o! the Co-S(*er&isor:.
'esearch Centre92T%-'C)2T%-''C::...
Programme:..
Mo$ile No: Phone ..

Application No.

%&&'IC%TI(N )(R* )(R UNI+"RSIT, "EVE" RESEARCH A(TIT$*E TEST -$"RAT.
Test Centre Code: "angalore "elga(m G(l$arga None
&rogramme Stream %pplied for:
1. Mechanical 8ngineering A. "io-Technology 15. Maths
3. Com*(ter Science 8ngineering 6. Polymer Science 1>. Physics.
5. 8lectrical 8ngineering D. Sil- Technology 1?. Chemistry
>. Ci&il 8ngineering 17. Te0tile 1@. Management St(dies
?. 8n&ironmental 8ngineering 11. Chemical 1A. Com*(ter A**lications
@ . Architect(re. 13. Geology 16. Ei$rary Science 1 1A.
Statistics 1D. Physical 8d(cation
Educational Qualification 95ic5 ma:es 8ou eligi7le for t5e (rogramme
Program egree A.arded S*ecialisation Percentage o!
Mar-s)CGPA .ith
Class
S*eci!y 'eg(lar or istance
8d(cation
%G
PG
ationalit8: Indian Others 9N'I)FN)PIO:: #ender: Male Female
Categor8: General SC ST Cat-1 O"C Any Other.
?5et5er (58sicall8 c5allenged /es No : I! /esB Nat(re o! disa$ility:....
Specif8 t5e status of VT$ TAT: Cleared in <(ly 3717 Cleared in <an 3711 Cleared in <(ly 3711
=rite the TAT Seat No.
ational Test @ualified 9it5 ;alid score
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>,
Are 8ou a facult8 under QI(+)I(: /es No
Address for correspondence:
VISVESVARAYA TECH!"!#ICA" $IVERSITY
ABnana sangamaC
Belgaum34D0 01E% 'arnata:a% India
Note:
1. This Form sho(ld $e !illed $y all the candidates irres*ecti&e o! their eligi$ility to $e e0em*ted !rom the %E'AT as
s(ch an e0em*tion is s($Cect to a thoro(gh scr(tiny o! s(**orting doc(ments satis!actorily *ro&ided $y the candidate
along .ith this A**lication
Seat No.:
)or !ffice $se onl8
Paste 9 do not *in :
*ass*ort si+e
*hotogra*h in this
s*ace and get it
attested $y
Princi*al ) ;ead o!
College ) %ni&ersity
last attended or a
Ga+etted O!!icer
To e filled - candidates
Name:
Address.

.......................................
Programme a**lied !or:
..
Candidate#s Signat(re
For those having
validity of VTU Tech.
Aptitude Test
ate o! %E'AT:
Test Centre:
'e*orting Time:
If 8ou possess VT$ $"RAT Test ;alidit8B then *ro&ide Seat No :...
.eclaration - the Candidate
Visit www.vtu.ac.in for Recognized Research Centres, Fee Structure and Syllabus for %E'AT.
Exemption from ULRA Test
The following categories of candidates will be exempted from appearing at the ULRA Test:
(a) Faculty embers under !"# $ F"# and
(b) %andidates &ualified in U'% $ U'%(%)"R *RF+
I here$y ac-no.ledge that all the in!ormation gi&en
$y me are tr(e to the $est o! my -no.ledge. In the e&ent o! any in!ormation $eing !o(nd incorrect or
misleadingB my candidat(re shall $e lia$le to cancellation $y the %ni&ersity at any time and I shall not $e
entitled !or re!(nd o! any !ee *aid $y me to the %ni&ersity. I ha&e care!(lly st(died the 'eg(lations9Amended:
Go&erning the egree o! octor o! Philoso*hy 9Ph..:-3711 !ramed (nder Section 53 o! 2T% Act 1DD>.
ate: Signat(re o! the Candidate