INDIAN INSTITUTE OF TECHNOLOGY MANDI

Application Form for Part-Time M.S./Ph.D. Admissions

(for College/University Faculty members from Himachal Pradesh and Jammu and Kashmir only)

1.  Proposed Discipline/Research Area

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2.  Proposed IIT Mandi Faculty Supervisor

3.  Name (As in qualifying degree certificate)

4.  Contact Details

Address for communication: / Permanent Address:
City: / Pin code / City: / Pin code
State: / State:
Telephone Number: / Mobile Number: / Email Address:
Alternate Email Address:

5.  General details

6.  Details of academic record (From 10th Onwards)

Degree / Year / University/Institution / Subjects / Percentage /Grade/CGPA

7.  Details of employment

Organization / Designation & pay / Duration
From / To

8.  Details of sponsored/consultancy project experience (if any)

S. No / Name of the project / Status/ Duration / Spons. Agency / Amount / Other Investigators
1.
2.

9.  Publication/Patent, here in number only (Attach separate list of publications as Annexure I)

·  Patent :

·  Book/Book Chapter :

·  International Journals :

·  National Journals :

·  Conferences / Seminars/ Symposia :

10.  Summary of past research/industrial experience and achievements

·  Attach separate sheet as Annexure II

11.  Awards & honors (please indicate title, organization and year)

·  Attach separate list as Annexure III (optional)

12.  Any other information

·  Attach separate sheet as Annexure IV (optional)

13.  List of Referees

Sl.No. / Name / Mailing Address, email and phone number
1.
2.
3.

Declaration

1.  I have carefully read the-advertisement and the Faculty research profiles uploaded on the IIT website.

2.  I hareby declare that the information given above is correct to the best of my knowledge and belief.

3.  I am aware that providing incorrect information in the application form can result in the cancellation of my admission at any stage.

Place:

Date: Signature of the Applicant

Name in capitals

Checklist

Signed and dated application form

Copies of marksheet/grade cards

Updated Curriculum Vitae

Copy of SC/ST/OBC certificate if applicable

Annexure I for list of publication

Annexure II for summary of past research and achievements

Annexure III for awards & honors (optional)

Annexure IV for any other information (optional)

Certificate of sponsorship from your institution (Original)

Research Proposal