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NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA, SURATHKAL

P.O. SRINIVASNAGAR, MANGALORE-575 025


Registration No.
(for office use only)

Admission to Ph.D. Programme 2014-15 (December Session)


(Under the category Full-time student with Institute Scholarship)
Area of Specialization __________________________________________________________________________
Name of the Dept. _____________________________________________________________________________
Particulars of D.D. drawn
Name of the issuing Bank ________________________________
Drawn at _____________________________________________
D.D. No. ____________________ dated ____________________
Instructions:

Rs. _____________

Category: OC / SC / ST / OBC / PWD


(Tick mark the appropriate)

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


2. Fill your address in the address slips & Registration Memo.
3. Enclose self attested xerox copies of marks card and other documents.
4. Late/incomplete/Applications without DD are liable to be rejected.

Affix self attested recent


Passport size photograph

6. Last date for submission of filled in application is 24.11.2014


1. Name of the Candidate in full (in Block Letters
as mentioned in the Degree Mark Card):
2. Address of the applicant (with pin code):

a. Permanent:

b. Correspondence

c. Telephone with STD Code or


Mobile No. :
d. Email :
3. Name and address of Father/Mother (or Guardian
if the parents are not alive, state relationship of
Guardian)

4. Occupation of Father/Mother/Guardian
Annual Income

5. a. Religion of the Candidate:.

Caste/Subcaste

b. Do you belong to Scheduled Caste/Tribe/OBC(Tick mark)


If yes, enclose a copy of the Caste Certificate issued from
Competent Authority

Yes / No

SC / ST / OBC

c. Place of domicile
d. Nationality
e. Do you belong to Persons with Disabilities (PWD) group?
(if yes, enclose copy of a medical certificate from a DMO)

6.

Yes / No

Date of Birth (Copy of the Supporting document to be enclosed)


In Figures:
In Words:

7.

Academic Record:
a) Post graduate Degree:
i.

Examination Passed

M.E./M.Tech./M.Sc./MBA/MA/CA
/if any other specify (Attach all marks card copies)

ii.

Specialization

iii.

Institute where he/she studied

iv.

Period of study

v.

University

vi.

Marks obtained in the Qualifying Examination (Masters Degree):

:
:
: from __________________ to ________________
:

(Attach all the marks card copies)

Year of
Passing

Marks/Grade
obtained

Max.
Marks

Percentage

Class/
Division

CGPA

I Sem

I Year

II Sem
III Sem

II Year

IV Sem

vii.

Aggregate percentage of marks (all semesters/years) / CGPA : ___________________________

Under graduate Degree:

b)

i.

Examination Passed

B.Tech/BE/B.Sc (Engg)/B.Sc/BA/AMIE/B.Com/
/if any other specify (Attach all marks card copies)

ii.

Specialization

iii.

Institute where he/she studied

iv.

Period of study

v.

University

vi.

Marks obtained in the Qualifying Examination:

:
:

: from __________________ to ________________


:

(Attach all the marks card copies)

Year of
Passing

I Year
II Year
III Year
IV Year

vii.

Marks/Grade
obtained

Max.
Marks

Percentage

Class/
Division

CGPA

I Sem
II Sem
III Sem
IV Sem
I Sem
II Sem
III Sem
IV Sem
Aggregate percentage of marks (all semesters/years) / CGPA : _________________________

8. Details of Practical Training under gone, if any, other than that required for graduate Course. Attach extra
sheet if necessary.
9. Professional/research or other Experience (Enclose Copies of Certificates from Employer)
Employer

Post Held/Nature of Job

10. Are you a Sponsored candidate?


(If yes, forward your application through your employer)

Period

Salary

11. DECLARATION OF CANDIDATE


I hereby declare that to the best of my knowledge, the particulars furnished in this application are correct.
I am willing to forfeit the seat secured for any course, if any information provided by me is false.
If selected for admission, I promise to abide by the conditions of admission and Rules of the Institute, and the
Academic Regulations that govern the programme of study/ research. I also promise to refund the entire Fellowship
amount drawn by me in case I discontinue the Programme at any stage before completion.
Place :
Date :

Signature of candidate

12. DECLARATION OF PARENT OR GUARDIAN


(Not applicable to candidates deputed on full salary by Institutions/ Industries)

In case my son/daughter/ward discontinues the course at any stage before completion without obtaining
permission from the Director and without repaying the fellowship amount drawn by him/her, I hereby undertake to
repay the Fellowship amount payable by my son/daughter/ward to the Institute.

Place:
Date :

In case declaration is signed by Guardian,


indicate relationship with the candidate

Signature of Parent or Guardian with Postal Address

Name
Relationship

Self attested Xerox copy of the following documents is to be enclosed.


1. Copy of the Marks Card of undergraduate and postgraduate Exam (all years/all semesters)
2. S.S.L.C./ X Std. Marks Card (for date of birth).
3. Caste Certificate issued by Competent authority for SC/ST
4. Persons with Disabilities (PWD) Certificate, if applicable.
5. Sponsorship letter for deputed candidates.
6. OBC Certificate in the Central Govt. format issued by competent authority in case of OBC.

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


INDEX SHEET Ph.D.
(READ INSTRUCTIONS OVERLEAF BEFORE FILLING)

1.

Full Name :

2. Student Category: Full time / External Registrant/Internal Registrant


M.Tech.

3. Qualification :

M.Sc.

Other

4. Details of Post graduate Degree:


a. Year of Passing qualifying exam (M.Tech./M.Sc./other)

b. Name of University :

c.

Name of the Institution :

d. Have you obtained your final semester/ year marks sheet :

YES

NO

PWD

OBC

e. Aggregate of Percentage of marks (all semesters/years) of qualifying degree/CGPA


5. Details of under graduate Degree :
a. Year of passing undergraduate Degree (BTech / BE/ B.Sc./Other)

b. Name of University :

c. Name of Institution :

d. Aggregate percentage of marks (all semesters / years) or CGPA.


OC

6. Reservation Category Code :

7. Experience (in years)

Teaching

SC

Research

ST

Field/Industry

All the above information are correct to the best of my knowledge.

Signature of the applicant

NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA


SURATHKAL, POST SRINIVASNAGAR, MANGALORE- 575025,
KARNATAKA STATE.

REGISTRATION MEMO.
Date:......... 2014
Ref: Application for admission to Ph.D. Programme
The Registration No. assigned to your application for admission is noted below, which must be
quoted in all correspondences connected with your application. No notice will be taken of any
communication or document sent by you unless it bears your Registration Number.
Registration Number:

Asst. Registrar (Academic)

Ph.D. ......../2014-2015

Affix
Stamp
Rs.6/-

To:
The Asst. Registrar (Academic),

Mr./Ms. _______________________

N.I.T.K., Surathkal

_______________________________

Post Srinivasnagar

________________________________

MANGALORE - 575 025.

_______________________________

(Write address of the candidate)


To

To:
_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

Pin Code ________ (__________ State)

Pin Code ___________ (________State)

To

To:
_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

Pin Code _________ (__________State)

Pin Code __________(__________State)

APPLICATION FOR

BY REGISTERED POST

ADMISSION 2014
Ph.D. Programme (December Session)
________________________________

From:

To:

____________________________

The Asst. Registrar (Academic),

____________________________

N.I.T.K., Surathkal

____________________________

Post Srinivasnagar

____________________________

MANGALORE - 575 025.

____________________________

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