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Form No.

Size 3.5 cm x 2.5


NATIONAL INSTITUTE OF TECHNOLOGY ANDHRA PRADESH cm
TADEPALLIGUDEM - 534102
Photograph
(Self-
Attested)
Application for admission to Ph.D (Full Time) /Ph.D
(Part Time)*/ M.S. (by Research)* for the Academic
Year 2019-20

(*For sponsored Candidates only)

FOR OFFICE USE ONLY

1. GATE/ NET: 2. Category 3. Status of the candidate 4. Payment Details:


(SC/ST/OBC (Tick whichever applicable)
Score:………………... /PwD/EWS/ Demand Draft No:.……………
General/Others) a. GATE/NET
Year: …………………… Drawn on ………………...
b. Non-Sponsored
Discipline: …………….. Amount …………………
c. Sponsored
Rank :………………….. Date …………..…………..

Bank Name and Branch:

TO BE FILLED BY THE CANDIDATE


1. Application Details:

Programme applied for Ph.D. (Full Time)/ Ph.D. (Part Time)/ M.S. (by Research):
(Write whichever is applicable)
Department/ School

Discipline/ Specialization

2. Details of Application Fees:


Demand Draft No.
Issuing Bank and branch Dated

3. Personal Details:
(i) Name (in capital)
(ii) Father’s Name

(iii) Mother’s Name

Address for
(iv)
correspondence
Pin - …………………………………. E-mail ID: ………………………………………
Telephone: …………………………………. Mob. No……………………
Permanent Address
(v)

Date of Birth ……….……/…….…..…/…………… Gender: Male/ Female/ Other


(vi)
DD /MM /YYYY Place of Birth_ _ State
(vii) Category SC/ST/OBC/PwD/UR/Others…………………………
(viii) Nationality ……….…………………………….

4. Educational Qualifications:
Please give the particulars of all the examinations passed and degrees obtained commencing with high
school leaving examination (Matriculation/10th standard)
Exam/ Degree
Year of % marks
Sl. No. obtained (with Subjects /Branch Board /Institute/ University Division
passing /CGPA
Discipline)

(i)

(ii)

(iii)

(iv)

(v)

5. Details of GATE/ NET (UGC/ CSIR)

Sl. No. Exam Year qualified AIR Rank Score

(i)

(ii)

6. Experience in Chronological Order: (Use separate sheet, if required)


Period Duration
Name & Address of Pay Scale/
Designation (YY/MM) Nature of work
Employer Salary From To
Declaration by the Candidate

I hereby declare that the information given above is correct. In case any of the information given by me
is found incorrect, my application is liable to be rejected / admission is liable to be cancelled.

Further, I assure that if admission is given to me, I shall abide by the rules and regulations, statutes,
and ordinances of the Institute and changes incorporated therein from time to time and shall maintain the
discipline of the Institute.

Signature of the Candidate


Place : ……………………………
Date : …………………………….

Employers Certificate for Sponsored Candidates

(A separate certificate must be enclosed with the Institute/Industry letter head)

This is to certify that Mr. / Ms. ……………………………………………………………………(Father’s /


Husband’s name) …………….………………. is working in ………………………………………………………….
(Name & address of Employer/ Organization/Institute) as……………………………….…………… on Regular /
Full time basis and he / she is sponsored and permitted to join the Part Time Ph.D./M.S. (by Research)
Programme of NIT Andhra Pradesh. If selected as a sponsored candidate, the organization has no objection
and he/she will be allowed to do Part Time Ph.D./M.S. (by Research) Programme of NIT Andhra Pradesh.

Date:
Place: Signature of Competent Authority with official seal

7. Check List (Please tick whichever applicable)


(Pl enclose Self attested copies of following documents as applicable)
th
a) 10 Marksheet / Certificates as proof of Date of Birth Yes/ No
b) Higher Secondary/10+2 Marksheet/Certificate Yes/ No
c) Marksheet/Grade Cards of Qualifying Examination (B.E. / B.Tech./ M.Tech etc.) Yes/ No
d) GATE Score Yes/ No
e) UGC-CSIR NET Certificate Yes/ No
f) Sponsorship Certificate with No Objection Certificate from present employer Yes/ No
g) Caste Certificate (For SC/ST/Other Backward Classes) in Govt. of India Format Yes/ No
h) EWS Certificate (Economically Weaker Sections) Yes/ No
i) PwD Certificate Yes/ No
j) Income Certificate from competent authority (for other Backward Classes) Yes/ No
k) Two passport size photographs Yes/ No
l) Demand Draft Yes/ No
m) Other documents if any __________________________________________________

Note: At the time of admission, all certificates and documents in original including migration & character certificate should be produced.

Signature of the Candidate


Verification Sheet (for Office use only)

1. Name: …………………………………...........

2. Category : UR/SC/ST/OBC/PwD/Others: ……………………

3. Branch at B.E./B.Tech./Equivalent ………………………………………………

4. UG Level year of passing …………………… Percentage/CGPA ……………………………….

5. Branch at M.E./M.Tech./Equivalent ………………………………………………

6. PG Level Year of passing …………………… Percentage/CGPA ……………………………….

7. GATE : Year of passing ……………Score …………Percentile………Rank………

8. NET: Year of passing ……………Score …………Percentile………Rank………

Comments by the scrutinizing committee:

Recommended/Not Recommended

(Signature of the scrutinizing officer & Team) (Signature of the HOD)

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