ANNA UNIVERSITY OF TECHNOLOGY, TIRUCHIRAPPALLI

TIRUCHIRAPPALLI - 620 024

APPLICATION FOR ADMISSION TO Ph.D. / M.S (BY RESEARCH) PROGRAMMES - JANUARY 2011

1. Name ( in Block letters) :

(with initials at the end) (Affix Passport Size
Photo Recently
2. Sex: Male / Female 3. Nationality: Indian / Foreign Taken)
Photograph to
4. If foreign national: Country___________ Passport No.________________ be attested by a
Grade A/B
Officer or by the
5. Social Status: OC/BC/MBC/DNC/SC/ST 6. Community ______________ Head of the
Institution last
Studied.
7. Age & Date of Birth: ________________ 8. Marital Status: Married / Unmarried

9. Email ID :

10. Address :

Office Address: Residential Address :

Designation : ___________________________ __________________________________

Organization : ___________________________ __________________________________

Place : ___________________________ __________________________________

__________________________ _________________________________

____________________________ __________________________________

Phone : Phone :
Mobile :
Mobile :

11. Category applied for : (Tick appropriate box, after referring Instructions)

Full Time Part Time (External) Part Time (Internal) Part Time (External)
Regular Faculty of all Project Staff of recognized Industry/ Research organization
Anna University departments of Anna University Recognized as a Research Centre
Colleges Colleges by this University

12. Details of current employment (if applicable)

Name & address of the employer:

Nature of employment : Regular /Approved Probationer / Probationer / Consolidated pay / Contract /

Visiting nature / Part – Time / Temporary

Scale of Pay: _________________________ working since date _________________

(Certificate from employer is to be attached)

13. Details of employment in project (if applicable)

Title of Project: ______________________________________________________________________________

Funding Agency: _____________________________________________________________________________

Pay: ____________________ working since date ______________ Expiry date of project _______________

(Copy of the project appointment order to be attached)

Note:The candidates working in Affiliated Engineering College situated in the districts of Ariyalur,Cuddalore,Nagappattinam
Perambalur,Pudukkottai,Thanjavur,Tiruchirappalli, and Tiruvarur are only eligible to apply under Part-Time category

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14. Academic Background :
(Start with the latest degree obtained)
(Enclose copies of Degree / Diploma Certificates duly attested)

Regular
Major % of
Degree / Year of Class Course /
Sl. No College University Discipline / Marks /
Diploma Passing Obtained Others
Specialization CGPA
(specify)

1.

2.

3.

4.

15. Professional Experience (Start from the present employment) :

Period
Organization From To Designation Salary P.M Nature of
Job

16. Awards, Medals, Prizes and Honors Conferred (if any) :

17. Major Area for Ph.D. Programme :

18. Tentative Topic of research (Attach one-page write-up :

Of proposed research, with candidate’s signature)

19. i) College in which the candidate proposes to register :

ii) Department in which the candidate proposes to register :
iii) Faculty :

Faculty of Engineering Faculty of Technology Faculty of Management Studies Faculty of Science & Humanities

20. Name, Designation and Address of the Supervisor

a) Supervisor (within the recognized departments of this University) :

b) Joint Supervisor (applicable for candidates from industry /
research Organizations recognized as a research centre by this University) :

21. D.D Particulars:

Name of the Bank & Branch Demand Draft No Date Amount

DECLARATION OF THE CANDIDATE

This is to certify that the particulars given above, are true, correct and complete to the best of my knowledge and
belief. I am aware that any wrong information or suppression of information and facts may result in punitive action in
addition to cancellation of my candidature for the Ph.D. admission.

Place :

Date : Signature of the candidate

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 CERTIFICATE FROM THE ORGANIZATION WHERE THE CANDIDATE IS EMPLOYED

Certified that Mr./Ms./Mrs._______________________________________ is employed as (Designation)

__________________________in the (Department / Division Name) ___________________________________ of (Institution Name)

___________________________________________________________________________________

We have no objection in forwarding his / her application for the Ph. D Programme

FOR FULL TIME :

* The candidate will be sanctioned leave for the duration of the research programme and will be relieved from

duty from ________________ to ___________________ to undertake the research work in the University/College for full time

study.

(or)

FOR PART TIME :

** The candidate will be permitted to undertake part time study in the University/College and will be allowed to

be present for discussions with the supervisor, attending course works, conduct of experiments and participations in seminars

and related presentations. Further the required facilities at our organization will also be provided to the candidate for doing

research.

(Note: Choose the appropriate * / ** marks)

Date : Signature of the Head of organization with office seal

CONSENT OF THE SUPERVISOR / JOINT SUPERVISOR

JOINT SUPERVISOR
SUPERVISOR
Applicable for candidates from Industry/ Research
(within the recognized departments of
Organization recognized as a Research Centre by
this University)
this University
Name

Designation

Department

College / Organization Address

Date of Birth

Area of Research

Whether the supervisor fulfills the YES / NO YES / NO

norms as per clause 7.4 of
Ph.D. Regulation If Yes Please furnish Univ. Ref. No. If Yes Please furnish Univ. Ref. No.

No.of Research Scholars

As on Date Ph.D Ph.D
As Supervisor
As Joint Supervisor

Signature

@ The supervisor while giving his/her consent should furnish the Panel of Members for DC in the format attached with the application

*** If the supervisor wants to guide in areas other than his/her Ph.D. degree, these areas shall be accepted based on two publications in referred
journals in the above areas or the staff member shall have handled PG level classes in the above areas, in the last three years preceding the date
of application.

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 DETAILS OF RESEARCH SCHOLARS PURSUING RESEARCH UNDER HIS/HER GUIDANCE

EITHER AS SUPERVISOR OR JOINT SUPERVISOR

(Shall be furnished by the supervisor while giving his/her consent)

INCOMPLETE DETAILS RESULTS IN REJECTION OF THE APPLICATION

Details of Ph.D. / M.S (By Research) Scholars:

SL.NO NAME OF THE SCHOLAR REG. NO. Ph.D. / SUPERVISOR RESEARCH

M.S. / JOINT STATUS
SUPERVISOR

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Note: The number of candidates registered under your guidance should not exceed ten.

Supervisor ID Number ------------------------------- Date ---------------------------

Name of the Proposed Superior : Signature

(Designation with Complete Official Address)

Contact No. Seal

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 ANNA UNIVERSITY OF TECHNOLOGY TIRUCHIRAPPALLI
TIRUCHIRAPPALLI - 620 024
CENTRE FOR RESEARCH
LIST OF PANEL MEMBERS FOR DOCTORAL COMMITTEE

(To be provided by Respective Guides in a separate Sealed cover)

Name of the Candidate :

Name of the Programme : Ph.D.

Research Topic of the Candidate :

Faculty :

Sl.No. Name with Initials Designation with full address Area of Research

1.

Phone:
E-mail:

2.

Phone:
E-mail:

3.

Phone:
E-mail:

4.

Phone:
E-mail:

5.

Phone:
E-mail:

6.

Phone:
E-mail:

SIGNATURE OF THE SUPERVISOR SIGNATURE OF THE HOD

(NAME WITH SEAL) (NAME WITH SEAL)

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 Course Ph.D. M.S. Office Ref. No.
DATA SHEET FOR Ph.D./M.S. (By Research) ADMISSION
(TO BE FILLED BY CANDIDATE – ALL LETTERS SHOULD BE IN CAPITAL LETTERS)

1.NAME
(As in UG/PG Degree with
initials at the end)

2. Date of Birth 3. Sex M F 4. Nationality Indian Foreign

5. Community: ST SC MBC BC OC

6. Social Status Married Unmarried

7. Communication
Address with
Email ID and
Mobile Number

8. B.Tech./B.E./B.Sc.(Engg.)/AMIE. / Others
Major:

Year of Passing Percentage of Marks/CGPA Mode of Study R O

University

9. M.Tech./M.E./M.Sc.(Engg.)/M.Sc./M.S.(By Research)/M.A./M.B.A./M.C.A./ Others

Major:

Year of Passing Percentage of Marks/CGPA Mode of Study R O

University

10. Employed Yes No (If Yes, provide Office address with designation; If No, provide Residential address)

11. Category Full - If Part

Applied for time - time

College Organisation Staff TRA Contract Project

12. Proposed Department for Research

and Institution address

13. Supervisor Name, Designation & Address

14. Joint Supervisor Name, Designation & Address

(If applicable)

15. Area of Research (Topic)

R – Regular O – Others (please specify)

SIGNATURE OF THE CANDIDATE