HOMI BHABHA CENTRE FOR SCIENCE EDUCATION, TIFR

V. N. PURAV MARG, MANKHURD, MUMBAI-400088

NIUS (CHEMISTRY) PROGRAMME

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Application Form - Batch XI (2014 - 2016)

Name of the Student: .................................................................................................................. .
Gender: Male /

Female

Date of Birth..

Permanent address: ..................................................................................................................... ..

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Address for correspondence: ...................................................................................................... .
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Email address: ............................................................................................................................ ...
Phone No. with STD code. (Residence) .....................................................................................
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Mobile:............

Name and Address of the College / Institution:.... ...................................................................... ....

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Course and year of Study: ...............................................................................................................
Main Subjects / Branch of study:....

Educational record:
Examination

Year of Passing Percentage of Marks

Board

Remarks

Class X
Class XII

Award / Fellowship:
YES/NO

Give details

Olympiad OCS Camp 2014

Others

I, the undersigned, agree to be an NIUS scholar for two years (2014-2016) and I shall try my best to
attend the NIUS camps regularly and work sincerely to make the best of this opportunity. I shall abide
by the norms and conditions, if any, stipulated under NIUS. I shall continue to pursue my present
degree programme equally conscientiously.

Date: Place: Signature:...............

Last date of receipt of applications is November 17th, 2014.

Checklist for Application: (No E-mail applications)
1. Application form or its equivalent (on plain paper), duly filled.
2. Self-Attested copies of your std. X and std. XII mark sheets
3. Two confidential assessment forms (send them in sealed and signed envelopes along with your
application).
4. Bona fide certificate from your current educational institute.
Send your completed applications alongwith the above mentioned document to the following
address so as to reach HBCSE, Mumbai on or before 17th November, 2014. Please write clearly
NIUS (Chemistry) 20142016 on the envelope.
Prof. Savita Ladage
Academic Coordinator, NIUS (Chemistry)
HOMI BHABHA CENTRE FOR SCIENCE EDUCATION
Tata Institute of Fundamental Research
V. N. Purav Marg, Mankhurd, Mumbai, 400 088