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Accredited by NAAC with A Grade

MHRD A Category University

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PIN or STAPLE

Recognised Research University

Application for Admission to M.Phil. / Ph.D. programmes offered at

Visakhapatnam, Hyderabad and Bengaluru Campuses for the year 2015 2016

FT PT
M.Phil

FT PT
Ph.D.
Last Date: 31st July 2015

(Mark)

1. NAME OF THE APPLICANT : (AS PER CLASS X OR EQUIVALENT MARKS MEMO)

3. GENDER ( Mark )

2. DATE OF BIRTH
DATE
4. CATEGORY ( Mark ) :

MONTH
OC

YEAR
SC

ST

MALE
PH

FEMALE

OTHERS

5. NATIONALITY
6. NAME OF THE PARENT / GUARDIAN:

7. ADDRESS FOR CORRESPONDENCE (DO NOT REPEAT NAME):

STATE :

PIN CODE :

8. STD CODE

MOBILE NUMBER

PHONE NO.

9. RESEARCH PROPOSED TO BE CARRIED OUT IN FACULTY

DEPARTMENT:
AREA OF RESEARCH
SPECIFIC TOPIC OF RESEARCH

10. PARTICULARS OF QUALIFYING EXAMINATION:

Qualifying PG /
M.Phil. Degree

Specialization

% Marks

Class

University

Year of
Passing

(PTO)

-2-

11. WHETHER QUALIFIED IN NET / GATE / GPAT: YES / NO

IF YES INDICATE TEST DATE AND SCORE:
12. FOR CANDIDATES APPLYING FOR M.PHIL. / Ph.D. PART-TIME:
i) NAME OF THE INSTITUTE WHERE THE CANDIDATE IS AT PRESENT WORKING:

ii) DESIGNATION
iii) TOTAL YEARS OF SERVICE

TEACHING

INDUSTRY

RESEARCH

Iv) WHETHER NO OBJECTION CERTIFICATE FROM THE PRESENT EMPLOYER IS ENCLOSED: YES / NO
13. FOR CANDIDATES APPLYING FOR M.PHIL. / PH.D. UNDER INTERDISCIPLINARY
i) NAME OF THE FACULTY AND DEPARTMENT WHERE MAJOR PART OF THE WORK IS PROPOSED TO BE CARRIED OUT:
FACULTY

DEPARTMENT

II) NAME OF THE FACULTY AND DEPARTMENT WHERE THE REMAINING WORK IS PROPOSED TO BE CARRIED OUT:
FACULTY
DEPARTMENT

14. FOR CANDIDATES APPLYING FOR Ph.D. UNDER EXTRAMURAL RESEARCH:

i) NAME OF THE ORGANISATION IN WHICH THE CANDIDATE IS AT PRESENT WORKING:

ii) DESIGNATION

iii) TOTAL YEARS OF SERVICE

iv) NAME AND DESIGNATION OF THE RESEARCH GUIDE FROM THE PARENT ORGANIZTION (OPTION):

v) WHETHER BIO-DATA OF THE RESEARCH GUIDE ENCLOSED: YES / NO

vi) WHETHER NO OBJECTION CERTIFICATE FROM THE PRESENT EMPLOYER IS ENCLOSED: YES / NO
15. DETAILS OF REGISTRATION FEE:
DD NUMBER

DD DATE

DD AMOUNT

ISSUING BANK

` 3000
Note: Please enclose the Demand Draft along with the Application. Mention your Name on the reverse of Demand Draft.

DECLARATION: I hereby declare that all the particulars stated in this application are true to the best of my knowledge and belief.
I shall abide by the rules and regulations of GITAM UNIVERSITY. In the event of submission of incorrect or untrue information at
the time of registration or in future, I understand that my admission is liable for cancellation. Further I understand that my
admission is purely provisional and subject to the fulfilment of the eligibility conditions. I agree to receive SMS on my mobile from
GITAM University.

SIGNATURE OF THE PARENT/GUARDIAN

SIGNATURE OF THE APPLICANT