NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA, SURATHKAL

P.O. SRINIVASNAGAR, MANGALORE-575 025

Registration No.
(for office use only)

Admission to Ph.D. Programme 2013-14 (December Session)

(Under the category Full-time student with Institute Scholarship)
Area of Specialization __________________________________________________________________________
Name of the Dept. _____________________________________________________________________________
Particulars of D.D. drawn
Name of the issuing Bank ________________________________
Drawn at _____________________________________________
D.D. No. ____________________ dated ____________________
Instructions:

Rs. _____________

Category: OC / SC / ST / OBC / PC
(Tick mark the appropriate)

1. Fill in the application form and the index sheet completely.

2. Fill your address in the address slips & Registration Memo.
3. Enclose attested photo copies of marks card and other documents.
4. Late/incomplete/Applications without DD are liable to be rejected.

Affix self attested recent

Passport size photograph

5. Last date for submission of filled in application is 25.11.2013

1. Name of the Candidate in full (in Block Letters
as mentioned in the Degree Mark Card):
2. Address of the applicant (with pin code):

a. Permanent:

b. Correspondence

c. Telephone with STD Code or contact number/

Mobile No. :
d. email (if any):
3. Name and address of Father/Mother (or Guardian
if the parents are not alive, state relationship of
Guardian)

4. Occupation of Father/Mother/Guardian
Annual Income

5. a. Religion of the Candidate:.

Caste/Subcaste

b. Do you belong to Scheduled Caste/Tribe/OBC(Tick mark)

If yes, enclose a copy of the Caste Certificate issued from
Competent Authority

Yes / No

SC / ST / OBC

c. Place of domicile
d. Nationality
e. Do you belong to Physically Handicapped (PH)/Physically Challenged (PC) group?
(if yes, enclose copy of a medical certificate from a DMO)

6.

Yes / No

Date of Birth (Copy of the Supporting document to be enclosed)

In Figures:
In Words:

7.

Academic Record:
a. i. Examination Passed

M.E./M.Tech./M.Sc./MBA/MA
any other (Attach all marks card copy of degree certificate)

ii. Specialisation

iii. Institute where he/she studied

iv. Period of study

: from __________________ to ________________

v. University

b. Marks obtained in the Qualifying Examination (Masters Degree):

(Attach copies of all marks cards)

Year of
Passing

I Year
II Year

I Sem
II Sem
III Sem
IV Sem

Marks/Grade
obtained

Max.
Marks

Percentage

Class/
Division

CGPA

8. .Details of Practical Training under gone, if any, other than that required for graduate Course. Attach extra sheet
if necessary.
9. Professional/research or other Experience (Enclose Copies of Certificates from Employer)
Employer

Post Held/Nature of Job

Period

Salary

10. Are you a Sponsored candidate?

(If yes, forward your application through your employer)

12. DECLARATION OF CANDIDATE

I hereby declare that to the best of my knowledge, the particulars furnished in this application are correct.
I am willing to forfeit the seat secured for any course, if any information provided by me is false.
If selected for admission, I promise to abide by the conditions of admission and Rules of the Institute, and the
Academic Regulations that govern the programme of study/ research. I also promise to refund the entire Fellowship
amount drawn by me in case I discontinue the Programme at any stage before completion.
Place :
Date :

Signature of candidate

Photo copy of the following documents to be enclosed.

1. Copy of the Marks Card of Qualifying Exam (all years/all semesters)
2. S.S.L.C./ X Std. Marks Card (for date of birth).
3. Caste Certificate issued by Competent authority for SC/ST
4. Physically Challenged Certificate, if applicable.
5. Sponsorship letter for deputed candidates.
6. OBC Certificate in the Central Govt. format issued by competent authority in case of OBC.

13. DECLARATION OF PARENT OR GUARDIAN

(Not applicable to candidates deputed on full salary by Institutions/ Industries)
In case my son/daughter/ward discontinues the course at any stage before completion without obtaining
permission from the Director and without repaying the fellowship amount drawn by him/her, I hereby undertake to
repay the Fellowship amount payable by my son/daughter/ward to the Institute.

Place:
Date :

Signature of Parent or Guardian with Postal Address

In case declaration is signed by Guardian,

indicate relationship with the candidate

Name
Relationship

14. FOR USE BY FORWARDING AUTHORITY (EMPLOYER)

Sponsorship (Deputation) Certificate/
No objection certificate
The applicant (name) .has been a permanent staff of
this

Institute/Organization

from

..

and

has

..

years

of

experience

(teaching/R&D/industry).
(a) Sponsorship/(Deputation) certificate:
He/She is sponsored (deputed) with full/half/no salary, for full time study/research in National Institute of
Technology Karnataka, Surathkal.
The candidate and his/her sponsorship (deputation)/ NOC will not be withdrawn before the completion of the
course/programme.
Official Seal
Station:

Signature of the Employer

Date :

Name:
Designation:

(Note: Sponsorship certificate should be submitted in the same format as indicated in this application form
duly signed by the Employer/ Sponsoring Institute Head and seal.)

N.I.T.K. SURATHKAL, SRINIVASNAGAR, MANGALORE 575 025

INDEX SHEET Ph.D.
(READ INSTRUCTIONS OVERLEAF BEFORE FILLING)

1. Full Name
2. Student Category :
3. Qualification

Full time
M.Tech.

M.Sc.

Other

4. Year of Passing qualifying exam (M.Tech./M.Sc./other)

5. Name of University

6. Name of the Institution:

7. Aggregate of Percentage of marks (all semesters/years) of qualifying degree
8. Reservation Category Code

9. Experience (in years)

OC

SC

ST

PC

OBC

Teaching

Research

Field/Industry

All the above information are correct to the best of my knowledge.

Signature of the applicant

NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA

SURATHKAL, POST SRINIVASNAGAR, MANGALORE- 575025,
KARNATAKA STATE.

REGISTRATION MEMO.
Date:......... 2013
Ref: Application for admission to Ph.D. Programme
The Registration No. assigned to your application for admission is noted below, which must be quoted in all
correspondences connected with your application. No notice will be taken of any communication or document sent by you
unless it bears your Registration Number.
Registration Number:

Ph.D. ......../2013-2014

Dy. Registrar (Academic)

Affix
Stamp
Rs.6/To:

The Dy. Registrar (Academic),

Mr./Ms. _______________________

N.I.T.K., Surathkal

_______________________________

Post Srinivasnagar

________________________________

MANGALORE - 575 025.

_______________________________

(Write address of the candidate)

To

To:
_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

Pin Code ________ (__________ State)

Pin Code ___________ (________State)

To

To:
_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

Pin Code _________ (__________State)

Pin Code __________(__________State)

APPLICATION FOR

BY REGISTERED POST

ADMISSION 2013
Ph.D. Programme (December Session)
________________________________

From:

To:

____________________________

The Dy. Registrar (Academic),

____________________________

N.I.T.K., Surathkal

____________________________

Post Srinivasnagar

____________________________

MANGALORE - 575 025.

____________________________