PDPM INDIAN INSTITUTE OF INFORMATION TECHNOLOGY, DESIGN AND MANUFACTURING JABALPUR APPLICATION FORM FOR ADMISSION TO M.Tech./M.Des/Ph.D. PROGRAMME (For filling this application form, see instructions overleaf) Paste your photograph here 1. Full Name : 2. Date of Birth (*) : 3. Place of Birth: 4. Sex: Male/Female 5. Marital Status: 6. Nationality: 7. Father s Name : 8. Address for Correspondence: Codes for Items 11-15 are given overleaf 11. Discipline State: Pin Code : 9. If available, please provide: Phone No.: Fax No. : Mobile No.: E-mail address: (Essential) 12. Category (*) 13. Student Status 14. Financial Status 15. Physically Handicapped 10. Details of Demand Draft a) Amount Rs. No... dt... b) Bank & Branch issued... 16. Academic Record/Work Experience A. GATE/CEED Details (*) Exam Name GATE/ CEED GATE/CEED Discipline B. Qualifying Degree (*) already obtained or in progress Valid GATE/ CEED Score All India rank University/Institute Discipline Degree Exam Date Final results expected by Master s Degree Qualified/ Not Qualified Exam Year Min. Pass Marks % or % Marks or Sem. I Sem II Sem. III Sem. IV Sem. V Sem VI Overall % or Bachelor s Degree % Marks or Sem. I Sem. II Sem. III Sem. IV Overall % or Sem. V Sem. VI Sem. VII Sem. VIII (if degree completed) C. Other Degrees (*) obtained after 10+2 (Do not include the degree listed in 16 B) University/Institute Discipline Degree Marks or CPI Date of completion D. Working Experience(**) Dates ( from to ) Employer Position Nature of Work (*) Attach attested copies of certificates, mark sheets, etc. See checklist overleaf for certificates required. (**) A candidate presently working (including those on projects) must provide a No Objection/Relieving certificate from the employer. 17. Declaration by the applicant: Certified that all information provided by me in this form is correct to the best of my knowledge and belief. I understand that any wilful misrepresentation of facts will result in my dismissal from the institute. If admitted, I shall abide by all the rules and regulations of the institute. Date : Signature :
Sponsorship Certificate from Employer (for candidates applying under sponsored category) The applicant Mr./Ms.. is working as. (Designation) in the scale of pay of Rs in this organization. He/ she is regular employee of the Institute/ organization since. and has been recommended and sponsored for admission to the M.Tech/ M.Des/ PhD Programme at PDPM IIITDM Jabalpur. If he/ she is selected, he/she will be permitted to proceed on leave from the date of commencement of the programme to full duration of the programme. Date: Name: Signature: Seal and address of :
Certificate from the employing organization* for External Registration of their employees in Ph.D programme of PDPM IIITDM Jabalpur --------------------------------------------------------------------------------------------------------------------------------------------------------------- The application of..... working as....... in since.... is herewith recommended and forwarded for admission under External Registration Scheme of the PDPM IIITDM Jabalpur for Ph.D. programme in the Discipline of 1. We note that the applicant has 2 year experience for admission to Ph.D programme in Engineering. 2. This organization has adequate facilities for carrying out the research indicated by the applicant and if he / she is selected, these will be made available to him / her during regular working hours till the completion of the programme. 3. The applicant will be deputed / given leave for duration of his/her residence period (till successful completion of comprehensive examination) at PDPM IIITDM Jabalpur. 4. Facilities will be made available to his/her Co-guide to supervise the work of the applicant and to attend the meetings at PDPM IIITDM Jabalpur when necessary. 5. Till the completion of his / her research programme, the applicant will not ordinarily be transferred to another unit or place which may impede his/her work under the scheme. If such a transfer is necessary, PDPM IIITDM Jabalpur will be informed within a month of such transfer. We understand that continuing of registration will depend on PDPM IIITDM Jabalpur s decision in this regard, taking into account all relevant factors. 6. We note that the facilities of the Institute will be made available to him/her for carrying out the research work and that there will be no separate charge (other than one semester full fees and registration keeping alive fee payable by the candidate) for the use of laboratory, library and other facilities. 7. No part of the work carried out in fulfillment of the Research programme will be utilized commercially or for applying for a Patent without the approval of PDPM IIITDM Jabalpur and other than on terms mutually agreed to by PDPM IIITDM Jabalpur and this organization. Date: Signature of the sponsoring Officer : Seal of the organization/ Name and Designation : Institution Postal address of the Organisation: * Following organizations may forward the applications of their eligible staff: Industry / Organisation having R&D facilities and recognized by DST, GoI or PDPM IIITDM Jabalpur National Laboratories Reputed Universities / Colleges Public sector / Private sector / Government Departments engaged in research/analysis jobs
External Registration Scheme at PDPM IIITDM Jabalpur Proforma for Relief Certificate Shri / Smt / Kumari.. employed as. is granted leave for 14 weeks (98 days) commencing from to and is relieved of his/her duties with effect from to.. to enable him/her to pursue M.S/Ph.D. Research programme under External Registration Scheme in July/ Jan... semester at the PDPM IIITDM Jabalpur as per their offer of admission letter No. dated.. Date : Signature of the Officer with name and address of the Organisation Office Seal
Admission to M.Tech./M.Des./Ph.D. (Sponsored) programme at PDPM IIITDM Jabalpur Proforma for Relief Certificate Shri. / Smt./ Kumari. employed as. is granted leave for 24 months/ 36 months commencing from.. to... and is relieved of his duties with effect from with full salary and allowances/ without salary and allowances to enable him/her to pursue M.Tech./ M.Des./Ph.D. programme under Sponsored Scheme in July / Jan.. semester at the PDPM IIITDM Jabalpur as per their offer of admission letter No. dated Date : Signature of the Officer with name and address of the Organisation Office Seal
INSTRUCTIONS FOR FILLING THIS FORM Separate application form should be used for each discipline. Either TYPE or PRINT the entries on the form neatly. Go through the codes for Items 11-15 given below and fill them carefully in the boxes on Page 1. All items marked with an asterisk (*) require you to submit an attested copy of some document. PLEASE DO NOT SEND ORIGINALS. Documents for which attested copies are required are given in the checklist. Please encircle the items in the checklist you are attaching with this form. Giving false information will lead to cancellation of admission. No column should be left blank. Write Not applicable against a column if the same does not apply to you. Tick ( ) the relevant box wherever provided. Application incomplete in any respect, is liable to be rejected. Candidates who are in the final year of their qualifying examination can be considered for admission only if they complete the requirement of their final examination including viva-voce before the registration date. The application fee of Rs. 200/- for candidates in general category/ OBC and Rs. 100/- for SC/ST candidates must be paid through demand draft in favour of The Registrar, PDPM IIITDM Jabalpur, issued by any nationalised bank, payable at Jabalpur. CODES (FOR ITEMS 11-15) Item 11: Discipline: {Computer Science & Engg. = CSE}, {Electronics & Communication Engg. = ECE}, {Mechanical Engg. = ME}, {Design=DES} {Mechatronics=MT} Item 12: Category: SC (*): Scheduled Caste (attested certificate required); ST (*): Scheduled Tribe (attested certificate required); GN: General; OBC (*): Other Backward Caste Item 13: Student Status: Regular: RG; Sponsored (*): SD; External (*): EX Item 14: Financial Status: Institute Assistantship requested: IA (For RG); Not Applicable: NA (For SD and EX) (Institute Assistantship is available only for the regular students with valid GATE/CEED score in case of MTech/MDes) Item 15: Physically Handicapped (*): PH (Physically handicapped certificate: Clearly mentioning % of disability) (*attested certificate required) CHECK LIST (ENCIRCLE THE ENCLOSED DOCUMENTS). SEND ONLY ATTESTED COPIES AND NOT ORIGINALS. 1. Date of birth (DOB) certificate or High School (Class Ten) Certificate with DOB (Required for all candidates) 2. SC/ST/OBC Certificate if applicable (Item 12) 3. Certificate of Physical Status (Type of disability to be attached). 4. Sponsorship certificate for sponsored/external candidates. (Item 14) 5. GATE/CEED score card (Item 16 A) 6. Copies of mark/grade sheets (Items 16 B & 16C) 7. No Objection / relieving Certificate from employer (for currently employed candidates) 8. The Demand draft for the application fee of Rs. 200/- (for General category & OBC) or Rs. 100/- (for SC/ST category) The completed Application Form must reach on or before Nov 08, 2011 The applicant must write the programme and the discipline applied for, on the cover of the envelope. Mailing Address for Applications: The Assistant Registrar (Academic) PDPM Indian Institute of Information Technology, Design & Manufacturing Jabalpur Dumna Airport Road, P.O Khamaria, Jabalpur- 482 005 India Kindly send your application form by Speed Post/ Registered Post only. Institute does not have any liability for loss of application if application is sent by Courier.