ANNA UNIVERSITY OF TECHNOLOGY MADURAI

ALAGAR KOIL ROAD, MADURAI - 625 002

APPLICATION FORM FOR RECOGNITION AS Ph.D. SUPERVISOR

1. Name (in Block Letters) :

2. Designation & Department : Affix passport
3. Official Address for size Photo
correspondence with pin code :

Residential Address :

4. Date of Birth :
5. Phone No. with STD code :
6. Mobile No. :
7. Email :
8. Qualification : (Starting from Higher to Lower)
Month & CGPA
Sl. No Degree University Branch Year of /Percentage
Passing & Class
1.
2.
3.
4.
5.
6.
7.
9. Area of Specialization :

10. Experience (no. of years)

i. Teaching
a. As Lecturer : From To
b. As Assistant Professor : From To
c. As Professor : From To
d. Total Teaching :

ii. Industry
a. Practical/ Industrial Experience :
b. Total Industrial Experience :
11. Membership & Fellowship in Professional Bodies
Sl. No Professional Body Category From To

12. Number of Sponsored Research Projects :

(as Principal investigator give details separately)
13. Research Guidance (No. of Thesis Guided) :
a. Master’s/M.Phil Thesis :
b. Ph.D Thesis :
14. Research Guidance (No. of Thesis Guiding) :
a. Master’s/M.Phil Thesis :
b. Ph.D Thesis :
15. Details of Supervisorship with other Universities :

16. Publications (Please attach list of publications and reprints of at least two publication published
in National/ International journals/referred journal proceedings)
a. No. of papers in referred journals :
i. National journals :
ii. International journals :
b. No. of papers published in referred
conference/ proceedings :
17. Patent filed/Granted :
18. Any other relevant information if any :
 DECLARATION
The information furnished above is true to the best of my knowledge.

Date :
Place :

Applicant Signature

Recommended / forwarded

Date :
Place : Signature/Head of Institution/Dean with seal

Encl: List of publication reprints, photocopy of PG and Ph.D Degree certificate