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Appln.

No:

ANNA UNIVERSITY OF TECHNOLOGY MADURAI


Alagar Koil Road, Madurai 625 002

For office use only

APPLICATION FOR ADMISSION TO RESEARCH PROGRAMME JANUARY 2012 (Tick whichever is applicable) Ph.D. M.S. (By Research)
1. Name (in Block letters with Initials at the end) 2. Sex 3. Nationality 4. If foreign national 5. Social Status 6. Community 7. Age & Date of Birth 8. Marital Status 9. Email Address
Affix recently taken passport size photo

: : : Male/Female Indian/Foreign Passport No___________

: Country____________ : : : : : Married/Unmarried

ST/SC/ MBC/BC/OC

10. Address:
Office Address: Designation : _________________________ Organization: _________________________ Place : _________________________ Residential Address: _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Pin code: _____________________________ Phone : ___________________________

Taluk/Dt./State:________________________ Pincode Phone Fax Mobile : _______________________ : ______________________ : ______________________ :_______________________

Fax : ________________________________ Mobile : ____________________________ Email: ___________________________

Email:________________________

11. Category applied for: (Tick appropriate box, after referring Instructions) FULL TIME 12. Details of Current employment (if Applicable)
Name & Address of the employer :

PART TIME

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Nature of employment

Regular/ Approved Probationer/Consolidated Pay/Contract/Visiting Nature /Part Time / Temporary/TRA

Scale of Pay:_____________________________ working since date:______________________ (Certificate from the employer to be attached)

13. Details of employment in project (if applicable) Name of the principal Investigator:__________________________________________________ (copy of the project sanction order to the principal investigator should be enclosed) Title of the project: ___________________________________________________________________________ Funding Agency :_________________________ Duration of the Project: ________________ Stipend:____________working since date___________ Expiry date of project:_____________ (Copy of the project staff appointment order should be attached) 14. Academic Background: (Enclose copies of Degree/Diploma Certificate duly attested from the latest degree obtained) Sl. No 1. 2. 3. 4. 5. 15. Professional Experience (Start from the present employment) Period Sl. Organization Designation No From To 1. 2. 3. 4. 16. Details of Publications in refereed journal (if any, Xerox copy shall be enclosed) : Degree/ Diploma Year of passing Major Discipline/ Specialization Class Obtained % of Marks/ CGPA Regular/Part time/ others (specify)

College

University

Total Salary (per Month)

Nature of Job

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17. Major area for Ph.D./M.S(By Research) Degree Programme

18. Tentative research topic

(One page write-up of proposed research with signature of Candidate & Supervisor should be enclosed) 19. i) College in which the candidate proposes to register :

ii) Department in which the candidate proposes to register

iii) Faculty 20. Name, Designation and Address of the proposed a) Supervisor

: CIVIL / MECH / ELECTRICAL / I & C / TECH / S & H / MANAGEMENT :

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

(* Refer: http://www.autmdu.ac.in/research for Approved Supervisors list.)

21. D.D Particulars: (Rs.600/- for General Candidates(Rs.300/- for SC/ST Candidates) drawn in favour of The Director, Centre for Research, Anna University of Technology Madurai, payable at Madurai.) Name of the Bank & Branch Demand Draft No. Date Amount

22. Awards, Medals, Prizes and Honors conferred if any : 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 Ph. D. / M.S. (By Research) programme admission.

Place: Date : Signature of Candidate

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CONSENT OF THE SUPERVISOR / JOINT SUPERVISOR (Recognized supervisors working in the recognized departments shall only function as supervisor ) * SUPERVISOR JOINT SUPERVISOR (should furnish the (Applicable only for candidates from University Ref. No. for Industry / Research Organisations Supervisorship Recognized by this University) Recognition) Name Designation Nature of Appointment Department College / Organization Address Date of Birth Area of Research Whether the supervisor fulfils the norms as per Ph.D. / M.S (by research) Regulations No. of Research Scholars As on Date As Supervisor As Joint Supervisor Total Signature * The supervisor while giving his / her consent should furnish the list of panel members for DC / MC in the enclosed format (page 5). A Supervisor shall not normally guide more than ten research scholars (including MS by Research Scholars) for Ph. D. at any time. Additional candidates, if any under extraordinary circumstances, shall be decided on the merit of the cases, subject to the approval of Research Board. Joint Supervisor is mandatory if the supervisor is not regular faculty member of this university. A maximum of ten research scholars only be permitted under such supervisors. YES / NO If Yes Please furnish University Ref. No. Ph.D. M.S. YES / NO If Yes Please furnish University Ref. No. Ph.D. M.S.

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

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Ph.D.

CENTRE FOR RESEARCH ANNA UNIVERSITY OF TECHNOLOGY MADURAI, MADURAI 625 002 LIST OF PANEL MEMBERS FOR DC / MC [To be sent in a sealed cover] (Tick whichever is applicable)

M.S. (By Research)


: :

Name of the Candidate Research Topic of the Candidate (Abstract of topic duly signed by the Supervisor should be enclosed) Name of the Supervisor Supervisor Recognition Ref. No. Sl. No.
1. Name : Designation : Department : Address : Mobile : Name : Designation : Department : Address : Mobile : Name : Designation : Department : Address : Mobile 1. :

: : Area of Research in Ph.D.

Name with full address

From Academic Institutions:

Email:

2.

Email:

3.

Email:

From Industry/R&D organizations:


Name : Designation : Department : Address : Mobile : Name : Designation : Department : Address : Mobile Name Designation Department Address Mobile : : : : : : Email: Email:

2.

Email:

3.

SIGNATURE OF THE HOD* (NAME WITH ADDRESS) *HOD of the Supervisor

SIGNATURE OF THE SUPERVISOR (NAME WITH SEAL)

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