Application for BIRAC Innovation Fellowship

under University Innovation Cluster (UIC)

ANNA UNIVERSITY, CHENNAI
This Application is divided into 6 parts: Personal profile, Educational qualification, Master/Doctoral
work, Professional experience, References and Project Proposal.
*Fields are mandatory.

Personal Profile:
*Applicant Type

Govt. Employed

Private Employed

Other (Mention
present status)

*Applicant Name

First Name

Middle Name

Last Name

Date of Birth

DD/MM/YY

Marital Status

Single/Married

*Gender

Male/Female

Do you belong to SC/ST

Yes/No

Contact Details:
*Present Address

Address

City/State/Pincode

City

State

Pincode

Tel (With STD Codes)

Home

Tel (With STD Codes)

Work

Can we contact you at work

Yes/No

State

Pincode

Mobile
Email
Permanent Address (if
different from present
address)

Address

City/State/Pincode

City

Educational Qualification:
Please list in chronological order, starting from matriculation onwards.
Name of the
Examination/Degree

University/
Board

Division/
Grade

Field of study /
Subject/s

Date of
passing

Place/
Country

1. Masters Research Work/Doctoral Work

Publications Authored/Co-Authored/Edited. Please list starting from latest (Please attach a
copy in word/pdf format)
Name of Journal

Impact factor
(Thomson
reuters)/
ISSN No.

Publication
Type (Review/
Research)

Vol , Page
number & Year of
Publication

2. Book or Book Chapters Authored/Edited

Name of
Publication

Impact factor (if

any)/ ISBN No.

Date of
Publication

Publication Type

Title of the
Article

3. Seminars/Conferences/Symposia Attended
Name

Place

National/ International

Whether
presented a paper
oral

Poster

4. Patents Filed/Granted
Title of the
Patent

Patent
Application
No.

Inventor
Name/s

Patent No.
(if Granted)

Technology
Area

Brief note on
commercial
feasibility (not
more than 150

words)

5. Any other Industry training program attended

Name of the Program

Specialized Area

Date

6. Award/ Fellowship
S. No.

Details

7. Research Projects completed/ in Progress

Research Undertaken
S. No.

Title of the Project

Funding
Agency

Duration
on years

Professional Experience: (Latest employment to the first employment)

Dates (Month/Year)

Location/Country

Employer Name1/
Address

Position Held
(with scale of pay, if
in service)

Amount
sanctioned

Responsibilities

Dates (Month/Year)

Location/Country

Employer Name 2/
Address

Position Held
(with scale of pay, if
in service)

Responsibilities

Continue on the table if necessary

Reference (at least two referees ):

May we request a reference?

Before offer of Fellowship

After offer of Fellowship

Work Reference

Academic Reference

Work Reference

Academic Reference

Work Reference

Academic Reference

Name 1
Job Title/Position
Telephone
Address
Email & mobile No.
Please indicate if this is a
work reference or an
academic reference
Name 2
Job Title/Position
Telephone
Address
Email & mobile No.
Please indicate if this is a
work reference or an
academic reference
Name 3
Job Title/Position
Telephone
Address
Email & mobile No.
Please indicate if this is a
work reference or an
academic reference

Project Proposal:
Broad Research Area (Tick one)

Bioprocess Technology
Healthcare diagnostic

(i)

Title of the Proposed Project

(ii)

Specific area

(i)

Objective

(ii)

Need

Commercialization approach

(1000 words maximum)

(1000 words maximum)

Milestones (six months each) with relevant

deliverables
Envisaged outcome at the end of the project
(Technology licensing/ Start up)
Any industry / mentor collaboration
(Is there any already identified partner /
mentor? If yes, please provide the details)
Declaration:
I declare that the information I have provided in this application form, to the best of my knowledge and
belief, is correct and complete.
If I include any details that you know to be false or if I withhold relevant information, I may render
myself liable to disqualification form the recruitment process or, if awarded the fellowship, to
withdrawn.

Name of the Applicant

Signature

Date:

Please note: Kindly ensure that all the required information is enclosed. It may not be possible to
consider a candidate for want of complete information.