NATIONAL INSTITUTE OF TECHNOLOGY (University)

(Established by Ministry of Human Resources Development, Govt. of India)

Yupia, District Papum Pare, Arunachal Pradesh – 791112

Fax: 0360-2284972, Email:

Application form for Admission in Online M.Phil in Economics, Planning and Development, and Entrepreneurship 2016-17

Application for Online M.Phil in ……………………………………………

1.  Name (in block letters)………………………………………………………..

(According to the school leaving certificate)

2.  Date of birth…………………… ……. Gender………………..Marital status…………

3.  Father’s name………………………………………………………………………………

4.  Mother’s name…………………………………………………………………………….

5.  Caste: General/SC/ST/OBC/Physically challenged

(Strike out which is not applicable)

6.  Nationality………………………………………………………………………………….

7.  Permanent address:

………………………………………………………………………………………………

………………………………………………………………………………………………

……………………………………………………………………………………………….

…………………………………………………………Pin Code………………………….

Mobile no.of the Guardian: Telephone No.:

E-mail of the parent (If any):

8.  Address for communication……………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………………………………….

Mobile No. of Applicant:……………………………………………………………………….

E-mail id of the applicant:::……………………………………………………………………

9. Draft No/ Fund Transfer receipt no. Name of the Bank

Amount: Date:

10. Are you GATE/UGC-JRF/UGC-NET/CSIR-NET/CSIR-JRF or equivalent test qualified?

If yes name of the qualifying test………………………………….

11. Particulars of Academic career:

Sl.no / Examination
passed / Name of
institute/
university / Year of
passing / Major
discipline / Total
marks
obtained / % of marks
/CGPA
1
2
3
4
5

(i)  Attested copies of all certificates and mark sheets of degrees etc. must be enclosed.

(ii)  Migration certificate, in original, must be submitted along with this registration form.

12. Experience:

Organisation served as employee** / Designation / Period / Pay
From / To

** Submit documents in support of your statement.

13. Present employment (in block letters) :

14. Name of organization…………………………………………………………

15. Nature of duty…………………………………………………………………..

Declaration certificate

(Strike out which is not applicable)

I am not pursuing any course of study at any other university/institution in India or abroad at present. Particulars given above are true and correct to the best of my knowledge and belief.

If, any information furnished by me, found false at any point of time during the tenure of course my registration will be treated as cancel. I shall be abided by the rules and regulations of the NIT(AP).

Date:

Place: (Signature of the applicant in full)

Employer’s certificate

Sri/Ms./Smt…………………………………………………………………………………… is a full time/part time employee of this organisation /institution/industry working in the capacity of………………………………………………………………. we have no objection to his/her pursuing online M.Phil at NIT Arunachal Pradesh as permitted under the rules.

Date:………………………..

Full signature with designation of the Employer

with official seal

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