APPLICATION FORM FOR VITERBI-INDIA PROGRAM

1. Name: First name Surname 2. Male Female Middle name

3. Date of Birth (dd/mm/yy): 4. Passport number: 5. Name of the University/Institution: 6. Address:

Institution / University Address Residential Address Landline Number # Telephone Alternative Telephone No. E-mail Mobile #

7. Major field of study: 8. Degree program currently enrolled in (e.g., BS, MS, B.Tech., M.Tech., Integrated BS/MS): 9. Cumulative Grade Point Average/ Percentage:

10. Expected date of Graduation (Completion of Degree): ____(mm) ____(yy)

11. Academic Record:

EDUCATIONAL QUALIFICATIONS (10th Standard onwards) Examination/ Degree University/ Board Institute/ College/ School Duration (from mm/yy to mm/yy) Subjects studied/ Specialization Percentage/ CGPA/ Rank

12. Research interests and possible project ideas. Please visit http://viterbi.usc.edu/summerinternship and Viterbi School faculty web-pages and list 2-3 faculty members you would be interested to work with. (Please attach a separate sheet if the space is insufficient).

13. Research experience, technical background, other internships, courses, lab work, techniques exposed to and past lab experience. (Please attach a separate sheet if the space is insufficient).

14. Career goals and what you hope to gain from this experience. (Please attach a separate sheet if the space is insufficient).

15. References (One of the referees should be your teacher/tutor. In case you have completed a training/internship in any lab, a reference from your supervisor there would be preferred. The references should be provided on the official letter-heads of the Referees and can be e-mailed directly to viterbi-india@indousstf.org).
REFERENCES (Please furnish details of persons who can provide an assessment of your suitability for this internship) Details Name of Referee Organisation Designation Relationship with Applicant Email id Phone number # Reference 1 Reference 2

16. Signed and stamped no objection certificate from Parent InstitutionThis should be given on the official letter-head of the parent institution/organization in the following format: STATEMENT FROM PARENT INSTITUTION This is to certify that this institution has no objection to the consideration of application for the Viterbi-India Program from Mr./Ms ..bonafide B.Tech./ M.Tech./ M.Sc. student in the (name of the department/institute/ organization) to undertake research internship at the University of Southern California for a duration of 8 weeks.

Place & date:

(Head of Institution/Organization)

17. Supporting Documentation check-list: Current transcript (Latest Marks sheet)

Two letters of recommendation from a faculty member, advisor or lab supervisor on their official letterhead No objection certificate from Parent Institution (in the format provided in S.No. 15)