VISVESVARAYA TECHNOLOGICAL UNIVERSITY, BELGAUM

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1 Full time Resume of Candidate Name: Gender: M F SC ST CAT-I Others No. of years of experience: Industry Teaching Research Qualification - Degree: UG:.PG: Specialization..... Number of Research papers: Patents: Awards: % Marks at UG: % Marks at PG: Attach Separate sheet for details Titles of the proposed course work (Detailed syllabus to be enclosed): SL.No Group Code Subject Part time Topic of Research proposed: VISVESVARAYA TECHNOLOGICAL UNIVERSITY, BELGAUM APPLICATION FORM FOR M.Sc. (Engg) Ph.D. Faculty: EL CV ME GS BA ARCH Paste ( do not pin ) passport size College / University last attended or a Telephone with STD Code/ Mobile: Date of Birth: D D M M Y Y Y Y DECLARATION OF THE APPLICANT I,, declare that the particulars furnished are true to the best of my knowledge and belief. I shall abide by all the prevailing and applicable rules and regulations of the University. Signature of the Applicant Recommendation of the Committee:. Recommended :. Recommended with conditions: FOR OFFICE USE ONLY. Rejected :

2 Signature of Head of the Institution Signature of Co - Guide Resume of Guide Name : Designation: Department : Name of the College: No. of years of Experience: Research Teaching Industry Area of Research : No. of Publications: Research papers : Communicated Conference Technical Reports Book Patents Awards No. of students Guided No. of Candidates registered: i) Ph.D.: : Under VTU Other University ii) M.Sc. (Engg.) by Research : Under VTU Other University Sl. No. Resume of Co-Guide Name of the Candidate/s Name : Registered under VTU or any other University (Specify) Year of registration Attach Separate sheet for details * Y Yes, N No. Status (whether acting as guide or co guide) Area of Specialization Status of Course work (No. of course works completed) Signature of Head of the Institution Comprehensive Viva-voce Completed Status of Progress of Research work No. of Papers presented/ published if any (Give details) Synopsis Submitted Designation: Organization: Area of Research: No. of years of Experience : Research Teaching Industry No. of Publications : Research papers Communicated Conference Technical Reports Thesis submitted Books Patents Awards No. of students Guided No. of Candidates registered : i) Ph.D : Under VTU Other University ii) M.Sc. (Engg.) by Research : Under VTU Other University Attach Separate sheet for details Grand Total: Final Viva voice completed & awaiting for convocation Signature of Guide Sl.No. Name of the Candidate/s Registered under VTU or any other University (Specify) Year of registration Attach Separate sheet for details * Y Yes, N No. Status (whether acting as guide or co guide) Area of Specialization Status of Course work (No. of course works completed) Comprehensive Viva-voce Completed Status of Progress of Research work No. of Papers presented/ published (Give details) Synopsis Submitted Thesis submitted Final Viva voice completed & awaiting for convocation

3 Applicant: Research Centre College : Department : Recognized: Yes No D.D. for Rs. 00/- No.: Drawn on Bank Date: DECLARATION OF THE EMPLOYER This is to certify that the organization has no objection in recommending the candidature of - for carrying out research for his / her Ph.D./M.Sc. (Engg.) by research at research centre on part time / full time basis. The information Provided by the candidate is found correct as per our records. Signature of the Employer with seal. UNDERTAKING FROM THE GUIDE I,. (Name & Designation) is a permanent faculty in the Department of. in the College and is aged less than years as on -0-00, hereby certify that the candidate Mr./Mrs.....registering for.... degree under VTU is not my son/daughter/immediate blood relative and the total number of candidates registered under me in VTU and other Universities for both Ph.D. & M.Sc. (Engg.) by Research taken together, including this candidate is (.)(in words and figures).the information provided above is true to the best of my knowledge. Date: Place: Signature : Forwarded by,.. Date: Signature of the Principal/Director/Head of the Research Centre with Seal of the College: DECLARATION OF THE GUIDE/CO-GUIDE(S) I / We have no objection in guiding the said candidate in the proposed area of research at the designated research centre. Signature of the Guide Signature of Co-Guide(s) Signature of the Head Of the Institution where the research work is proposed

4 CHOICE OF TECHNICAL APTITUDE TEST CENTRE Whether appeared for Technical Aptitude Test in the Month Jan 009 / July 009 & Qualified: Yes a) If Yes furnishes the details Technical Aptitude Test Hall Ticket No : b) Please tick the choice of Technical Aptitude Test Centre : Belgaum Bangalore No Guide: Mobile No: Co-Guide-: Mobile No: Note: Documents to be enclosed (Check list): Yes No. Tick ( ) the appropriate boxes. i) Detailed bio-data of the candidate and guides.. Enter the numbers in appropriate boxes like number of Awards etc., ii) Copies of UG/PG Degree certificates of the candidate. iii) UG, PG & Ph.D., certificate of the guide. iv) Details of course work.. Percentage is to be entered as considered for the award of the Degree for both UG and PG to the nearest integer.. The minimum prescribed qualification for a guide is Ph.D. in the relevant area. v) Synopsis (one copy only). Incomplete applications shall be rejected. vi) D.D. for Rs.00/- in favour of Finance Officer payable at VTU, Belgaum.. In case more than one Co-guide is proposed, a separate sheet may be attached. Please Note: For details syllabus for Technical Aptitude Test visit our website Ph.D./M.Sc.(Engg) File No: Office use only Name of the Applicant: Name of the Guide: Research Centre: Department: Mobile No: Land line OFFICE USE ONLY Test Qualified: Absent in Test Others. Recommended. Recommended with condition. Rejected. Recommended. Recommended with condition. Rejected

5 Candidate Copy Visvesvaraya Technological University Name: Paste ( do not pin ) passport size College / University last attended or a Department : Test Centre : Bangalore Test Centre : Office Use only Belgaum Candidate Signature Seat No: Time:.00 am to.00 pm Signature of the Special Officer Office Copy Visvesvaraya Technological University Name: Paste ( do not pin ) passport size College / University last attended or a Department : Test Centre : Bangalore Test Centre : Office Use only Belgaum Candidate Signature Seat No: Time:.00 am to.00 pm Signature of the Special Officer