Summer Internship Programme –2017 @ IIT Palakkad

Application form

Please fill in all the details asked for.

(This form needs to be filled in, printed out, signed, and scanned. The scanned copy should be emailed to: . Further, a certificate in the format given at the end of this form, needs to be attached.)

  1. Personal details
  1. Name:
  1. Gender:
  1. Date of birth:
  1. Email:
  1. Telephone number (Landline/ Mobile):
  1. Full postal address for correspondence:
  1. Permanent address (If different from the above) :
  1. Emergency Contact Number:
  1. Academic details (Please see the eligibility criterion given on the Institute website before filling this section.)

(a)  Details of Class X and XII

Year / Maximum marks
(%) or CGPA / Marks obtained (%) or CGPA / Institution/Board
SSLC/Class X
PUC/ Class XII

(b)  Graduation (Bachelor’s Degree: B.Sc. degree or B.Tech degree or First three years of an Integrated Master’s program)

Name of the course :

Institution :

Semester / Year / Maximum marks (%)/SGPA / Marks obtained (%)/SGPA
I
II
III
IV
V
VI
VII
VIII
CGPA (overall)

(c)  Post Graduation (M.Sc./M.Tech.)

Name of the course :

Institution :

Semester / Year / Maximum marks (%)/SGPA / Marks obtained (%)/SGPA
I
II
III
IV

Important Note : Originals of all mark/grade sheets will have to be produced at the time of joining.

  1. Applicant’s areas of interest (A write up, not exceeding 250 words, about what you would like to do and achieve through this fellowship):
  1. Give names of one or more faculty members at IIT Palakkad, with whom you would like to be associated:
  1. In the past, have you done any project in any other Institute? If so, please give details:
  1. Are you currently a recipient of any fellowship? If yes, provide the name and duration of the fellowship:
  1. Any other information that you would like to add, in support of your application:
  1. Declaration: I affirm that the information given above is correct.

Signature :

Place :

Date :

Important:

A certificate from the Head of the institution where the candidate is studying, made in the letterhead of the institution, in the format given below has to be scanned and sent with the application.

This is to certify that Mr/Ms. ……………... Roll No. ……………….. is a bona fide student of this Institute.

a)  In the current academic year (2016-2017), he/she is studying in the …………... year of B.Sc./M.Sc./B.Tech/M.Tech/MS/Integrated MS/Mtech.
or

b)  In the current academic year (2016-2017), he/she completed the undergraduate programme B.Sc./B.Tech.

This certificate is issued for the purpose of applying for Summer Internship Programme 2017 (May 2017 to July 2017) in IIT Palakkad.

Head of the Institute

(with seal)