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PARTA

CATEGORY:______

GIPEDIAPPLICATIONFORM

BATCH:

Year:

____(1/2/3/4)

Mode:

EARLYDECISION
REGULARDECISION

Startingon: 15JAN/MAY/JULY/DEC Endingon: 14JAN/MAY/JULY/DEC(CHOOSEDATES)

FromTable3
oFemale?
GENDER

Name:
FIRSTNAME

MIDDLENAME

SURNAME

Mailing

PHOTOWITHWHITE
BACKGROUNDWEARING
WHITEORLIGHTCOLORED
CLOTHING(pleasewriteyour
nameontheback)

Address:

(____)

Tel#:

Mobile:

_ _ / _ _ / _ _ _ _
D D
M M Y Y Y Y
DATEOFBIRTH

email(s):
OFFICIALEMAILADDRESSFIRST;ALTERNATIVEFREEEMAILADDRESSESALSOMAYBEGIVENASSECONDEMAIL

Discipline
CURRENTINSTITUTE:
ACADEMICPROFILE(ONLYSTATEMARKSOBTAINED;DONOT ENCLOSECOPIESORORIGINALSOFANYCERTIFICATE)
Class10:
LANGUAGE1

SCIENCE

MATHS

PHYSICS

CHEMISTRY

BIO

MATHS

SEM1

SEM2

SEM3

SEM4

SEM1

SEM2

SEM3

SEM4

LANGUAGE2

AGGREGATE

RANK,IFANY

OTHER: LANGUAGE1

AGGREGATE

RANK,IFANY

AGGREGATE

RANK,IFANY

SST

Class12:
BACHELORS
SEM5

SEM6

SEM7

MASTERS
RANK,IFANY

PROPOSED TOPIC OF
INTERNSHIP (ONE
ONLY):

IhaveattachedmyStatementofPurposeseparately(StatementofPurpose:Pleaseattachseparatelyseepage20(maximum1
pagetypedinsinglespace12ptfont).

Ihaveattacheddescriptionsofmyprojectsdonesofar(Attachseparately(maximum1typedpage)seepage21givingdetailsof
teamsize,yourspecificcontributions,thedeliverables,significanceofwhatyoudidandhighlightingobjectivesmet.)

CONCURRENCEOFFACULTYMENTORINIITDELHI(OPTIONAL[seeFAQ2.10]/ONLYNEEDEDIFYOUALREADYHAVEA
MENTOR'SCONSENTdonotfillanameifyouhavenotobtainedaprioragreementinwritingfromtheproposedFacultyMentor ):
Signature:

FACULTYMENTORINIITD:

OfficeTel:

IITDemail:

Date:

(BeforeconsentingtobecomeFacultyMentors,FacultyareadvisedtoseeGUIDELINESFORSELECTINGSTUDENTSavailableat
http://sites.google.com/site/gipediinterns/guidelinesforfacilitators)
IhavereadtheGUIDELINESFORSELECTINGSTUDENTS(FacultyMentormustfillthisbox)
IhavefilledandsignedtheFacultyConsentForminPartBandenclosedit(FacultyMentormustfillthisbox)
LOCALADDRESS(REQUIREDONLYFORAPPLICANTSWHOARENOTAPPLYINGUNDERANYMoU
SUCHASIASc,KVPY,etc)
I state that I have a local address to stay in Delhi / NCR and, if selected, will make my own
arrangements for stay and travel to IIT Delhi as per Internship timings without any pre-conditions

INSTITUTIONALCONSENT(FROMTPO):
Iforwardthisapplication,havingreadand
agreeingtocomplywithalltermsand
conditionsoftheGIPEDI.

LOCAL
Address:
Signature
Tel#:

(____)

Mobile:

NAME:

email(s):

Seal:

OFFICIALEMAILADDRESSFIRST;ALTERNATIVEEMAILADDRESSESALSOMAYBEGIVENASSECONDEMAIL

DECLARATIONBYTHEAPPLICANT
1 Iherebycertifythatbysigningandsubmittingthisapplication,Icertifytheabovefactstobetrue.

NAME:

2 IalsoagreethatifIapplyforanyBatchotherthanaupcomingBatch(i.e.anybatchforwhichtheapplicationisnotbeing
advertised),theapplicationfeesshallbeforfeitedandmyapplicationshallnotbeprocessedfurtherunlessIhaveappliedunder
theEarlyDecisionScheme.
3 Indemnity:Ialsotakefullresponsibilityforanyaccident/lossandagreetoinsuremyselfagainstanysuchaccident/lossoflife/
disabilitytomyselfarisingdirectlyorindirectlydueto/duringtheinternship.IagreethatFITTorIITDelhiwillNOTbeheld
responsibleorliableforcompensationinanymannerforanysuchaccident/lossoflife/disabilitytomyself.
oEDAPPFEEs
PAYMENTDETAILS EXEMPT

DATE:
PLACE:

DD#:
Signature

Rs:

BANK:

Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

GIPEDIAPPLICATIONFORM

CATEGORY:______
FromTable3

STATEMENTOFPURPOSE:Ifyouneedtoincluderichmediaormatterwhichcannotbeenclosedastextsuchasvideo,images,
audiopleasefeelfreetogiveaweblinkbelowwherethemediacanbefound.PleaseuseaURLshorteningservicesuchas
bitly.comortinyurl.com.
Ihavemoreinformationwhichcanbefoundat:

http://

Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

GIPEDIAPPLICATIONFORM

CATEGORY:______
FromTable3

StatementofProjectAbstracts/WorkExperience(Foreachproject,pleasegivethetitle,teamsize,yourrole,scopeofwhat
youdid,significanceofwhatyoudid,approximatemandays,anyreferee(s)andtheircontactemailandphone) Ifyouneedto
includerichmediaormatterwhichcannotbeenclosedastextsuchasvideo,images,audiopleasefeelfreetogiveaweblink
belowwherethemediacanbefound.PleaseuseaURLshorteningservicesuchasbitly.comortinyurl.com.
Ihavemoreinformationwhichcanbefoundat:

http://

Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

GIPEDIAPPLICATIONFORM

CATEGORY:______
FromTable3

TellusaboutyourselfintheformofanessayaboutwhatyouexpecttoachieveasanIntern( highlightanythingspecialwhich
youthinkwillallowyoutocontributetothecommunityhereatIITDelhi ).Ifyouneedtoincluderichmediaormatterwhich
cannotbeenclosedastextsuchasvideo,images,audiopleasefeelfreetogiveaweblinkattheendwherethemediacanbe
found.PleaseuseaURLshorteningservicesuchasbitly.comortinyurl.com.
Ihavemoreinformationwhichcanbefoundat:

http://

APPLICANT RECOMMENDATION FORM (please photocopy this blank form if you need more LoRs)
Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

CATEGORY:______

GIPEDIAPPLICATIONFORM

FromTable3

(please ensure that you print or photocopy both pages of this form on the two sides of the same sheet of paper, not on separate sheets)
Please answer the following questions (no box should be left unfilled in this table as that will disqualify the recommendation ) :
(FITT/IITD OFFICE to insert) the Handling # here :
Respondent Referee's Name
Title (Prof. / Dr. / Mr. / Ms.)

Applicant Name:

Designation

Year / Discipline:

Institution/Employer

Desired Area of Work:

Email address (ONLY


OFFICIAL EMAIL ADDRESSES
PLEASE)
Phone # (with STD code)
(Area code)

Phone number:

(Areacode)

Do you know the applicant personally (as a No / Yes(specify how)


relative / friend etc) ?

Respondent Referee's Postal


Address:

For Respondent Use Only


Please evaluate the applicant by placing a check after each characteristic to be evaluated in the column that most nearly represents your opinion. Compare the
applicant with a representative group of students qualified for graduate study to whom you have known and who have had approximately the same amount of
experience and training as the applicant. If you lack knowledge to make a definite rating, give your estimate of applicant's ability and also check the column
"Inadequate Opportunity to Observe."
Inadequate
opportunity to
observe

Below average Average

Good

Superior

Outstanding

On what specific basis do you


assign the particular rating given ?

Analytical Ability
Research Ability
Ability to master academic work
Fundamental knowledge in field
Skill/originality of research work
Lab / hands-on skills
Research productivity (papers
published/ talks given etc)
Ability in oral expression
Ability to write
Motivation towards a career
Initiative
Emotional stability and maturity
Self-reliance and independence
Ability to work with others
Ability to work in multicultural
environment
Leadership potential
Integrity
Creative or innovative talent
Imagination / Original thought
Potential for success in chosen
area
Growth observed during period
OVERALL RATING
OVERALL RANKING

 Best student this year  Best student in . Years  Top .% of students this year  Unable to rank

Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

CATEGORY:______

GIPEDIAPPLICATIONFORM

FromTable3

Against which group are you rating the applicant ? For example, all under-graduate students I have taught in the past four years.

How long have you known the applicant ?

years and

As  As Research Advisor

months

 As Course Advisor

 As teacher (one course)  As teacher (several courses)


 As Departmental Head / Chair
 Other .

What do you consider the applicant's most outstanding talents or characteristics?

What are the applicant's chief weaknesses, or areas for growth ?

Please answer the following:


NO

NO

NO

YES

UnNot
Fairly
Not Applicable
enthusiastical
recommended
strongly
ly

YES

YES

Strongly

Enthusiastically
, without
reservation

1) Would you accept this applicant to your internship program?


2) If recommended, would you offer financial assistance if
available?
Overall recommendation is:
Please add (by means of attachment, if needed) any comments that will assist in our making a judgment as to whether the applicant should be accepted to the
Internship Program of IIT Delhi

Please type your name, understanding that it is legally equivalent to your signature (if this recommendation is sent by electronic means) and constitutes your
certification that your responses and assessments are accurate and fair to the best of your knowledge.
Full Address of respondent (in
capitals)

(Name)
(Line1)
(Line2)
(City)PIN
State:

Signature of Respondent

Date
Place

PLEASESIGN,SEALSECURELYINAENVELOPEANDRETURNTOAPPLICANT.
ThecontentsofthisletterareCONFIDENTIALandmustNOTbeshowntotheApplicant.
ThelettermustbefilledinbytheRefereeinhis/herownhandwriting.
TherecommendationisonlyacceptableinthisformataseparateLetteronyourLetterheadisnotacceptable.
Thankyouforyourtime.

APPLICANT RECOMMENDATION FORM


(please ensure that you print or photocopy both pages of this form on the two sides of the same sheet of paper, not on separate sheets)
Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

CATEGORY:______

GIPEDIAPPLICATIONFORM

FromTable3

Please answer the following questions (no box should be left unfilled in this table as that will disqualify the recommendation ) :
Respondent Referee's Name
(FITT/IITD OFFICE to insert) the Handling # here :
Title (Prof. / Dr. / Mr. / Ms.)

Applicant Name:

Designation

Year / Discipline:

Institution/Employer

Desired Area of Work:

Email address (ONLY


OFFICIAL EMAIL ADDRESSES
Phone # (with STD code)
(Area code)

Phone number:

(Areacode)

Do you know the applicant personally (as a No / Yes(specify how)


relative / friend etc) ?

Respondent Referee's Postal


Address:

For Respondent Use Only


Please evaluate the applicant by placing a check after each characteristic to be evaluated in the column that most nearly represents your opinion. Compare the
applicant with a representative group of students qualified for graduate study to whom you have known and who have had approximately the same amount of
experience and training as the applicant. If you lack knowledge to make a definite rating, give your estimate of applicant's ability and also check the column
"Inadequate Opportunity to Observe."
Inadequate
opportunity to
observe

Below average Average

Good

Superior

Outstanding

On what specific basis do you


assign the particular rating given ?

Analytical Ability
Research Ability
Ability to master academic work
Fundamental knowledge in field
Skill/originality of research work
Lab / hands-on skills
Research productivity (papers
published/ talks given etc)
Ability in oral expression
Ability to write
Motivation towards a career
Initiative
Emotional stability and maturity
Self-reliance and independence
Ability to work with others
Ability to work in multicultural
environment
Leadership potential
Integrity
Creative or innovative talent
Imagination / Original thought
Potential for success in chosen
area
Growth observed during period
OVERALL RATING
OVERALL RANKING

 Best student this year  Best student in . Years  Top .% of students this year  Unable to rank

Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

CATEGORY:______

GIPEDIAPPLICATIONFORM

FromTable3

Against which group are you rating the applicant ? For example, all under-graduate students I have taught in the past four years.

How long have you known the applicant ?

years and

As  As Research Advisor

months

 As Course Advisor

 As teacher (one course)  As teacher (several courses)


 As Departmental Head / Chair
 Other .

What do you consider the applicant's most outstanding talents or characteristics?

What are the applicant's chief weaknesses, or areas for growth ?

Please answer the following:


NO
Not Applicable

NO
Not
recommended

NO

YES

YES

UnFairly strongly Strongly


enthusiastically

YES
Enthusiastically,
without
reservation

1) Would you accept this applicant to your internship program?


2) If recommended, would you offer financial assistance if
available?
Overall recommendation is:
Please add (by means of attachment, if needed) any comments that will assist in our making a judgment as to whether the applicant should be accepted to the
Internship Program of IIT Delhi

Please type your name, understanding that it is legally equivalent to your signature (if this recommendation is sent by electronic means) and constitutes your
certification that your responses and assessments are accurate and fair to the best of your knowledge.
Full Address of respondent (in
capitals)

(Name)
(Line1)
(Line2)
(City)PIN
State:

Signature of Respondent
Date
Place

PLEASESIGN,SEALSECURELYINAENVELOPEANDRETURNTOAPPLICANT.
ThecontentsofthisletterareCONFIDENTIALandmustNOTbeshowntotheApplicant.
ThelettermustbefilledinbytheRefereeinhis/herownhandwriting.
TherecommendationisonlyacceptableinthisformataseparateLetteronyourLetterheadisnotacceptable.
Thankyouforyourtime.

Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

PARTA

GIPEDIAPPLICATIONFORM

CATEGORY:______
FromTable3

Pleasesendthecompletedapplicationto:GIPEDIProgram,FITT(Attn:Prof.SubratKar/Mr.K.K.Roy),IITDelhi,HauzKhas,NewDelhi110016India

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