Annexure-I

Government of India
Ministry of Human Resource Development
(Department of Higher Education)

PROFORMA OF APPILICATION FOR INTERNSHIP-2014

1. Name of applicant
[in full Block letters only]

2. Sex


3. Nationality

4. Date of Birth


5.
Fathers/Husbands name


6. Correspondence address[with Pin Code]






7. Permanent address[with Pin Code]






8. Contact Details

(a) Telephone Number


(b) Mobile Number


(c) E-mail address


(d) Name, Relationship and contact details of
Person to be contacted in case of any
Emergency

9. Details of the Courses of Study

(a) Name of the Course



(b) Duration






-2-
(c) Name of the Institution







(d) Date of joining Institution


(e) Expected date of completion



10. Educational Qualification (Starting from 10
th
onwards)

Name of
Board/University/Institution
Exam
Passed
Year Division/
Grade
Subjects

(i)



(ii)




(iii)




(iv)





11. Subjects of specialization/intrest





12. Projects preferences/if any





13. Brief Note why you want to take up this
Internship[should not exceed 50 words]








13. Details of scholarship, if any availed by you
along with quantum of amount and duration





14. Names and contact details of two references from
the present Institution or the Institute last attended


(i)



(ii)



15. Any other relevant in formation








Place:

Date: Signature of the applicant



DECLARATION

I certify that the above mentioned information furnished by me is true to the best
of my knowledge and belief. I also agree in the event of any misrepresentation and / or
falsification of information , my internship shall be liable for termination without any
further notice without prejudice to any other administrative / legal proceedings that the
Ministry may deem fit to initiate.


Place:

Date: Signature of the applicant