Application for BIRAC Innovation Fellows

Application for BIRAC Innovation Fellows

Application for BIRAC Innovation Fellows

underUniversity Innovation Cluster (UIC)

ANNA UNIVERSITY, CHENNAI

This Application is divided into 6 parts: Personal profile, Educational qualification, Master/Doctoral work, Professional experience, References and Project Proposal.

*Fields are mandatory.

Personal Profile:

*Applicant Type / Govt. Employed / Private Employed / Other (Mention present status)
*Applicant Name / First Name / Middle Name / Last Name
Date of Birth / DD/MM/YY
Marital Status / Single/Married
*Gender / Male/Female
Do you belong to SC/ST / Yes/No

Contact Details:

*Present Address / Address
City/State/Pincode / City / State / Pincode
Tel (With STD Codes) Home / Tel (With STD Codes) Work / Can we contact you at work / Yes/No
Mobile
Email
Permanent Address (if different from present address) / Address
City/State/Pincode / City / State / Pincode

Educational Qualification:

Please list in chronological order, starting from matriculation onwards.

Name of the Examination/Degree / University/ Board / Division/
Grade / Field of study / Subject/s / Date of passing / Place/
Country
  1. Master’s Research Work/Doctoral Work

Publications Authored/Co-Authored/Edited.Please list starting from latest(Please attach a copy in word/pdf format)

Name of Journal / Impact factor (Thomson reuters)/ ISSN No. / Publication Type (Review/ Research) / Vol , Page number & Year of Publication
  1. Book or Book Chapters Authored/Edited

Name of Publication / Impact factor (if any)/ ISBN No. / Date of Publication / Publication Type / Title of the Article
  1. Seminars/Conferences/Symposia Attended

Name / Place / National/ International / Whether presented a paper
oral / Poster
  1. Patents Filed/Granted

Title of the Patent / Patent Application No. / Inventor Name/s / Patent No.
(if Granted) / Technology Area / Brief note on commercial feasibility (not more than 150 words)
  1. Any other Industry training program attended

Name of the Program / Specialized Area / Date

6.Award/ Fellowship

S. No. / Details
  1. Research Projects completed/ in Progress

Research Undertaken
S. No. / Title of the Project / Funding Agency / Duration on years / Amount sanctioned

Professional Experience: (Latest employment to the first employment)

Dates (Month/Year) / Location/Country
Employer Name1/Address / Position Held (with scale of pay, if in service)
Responsibilities
Dates (Month/Year) / Location/Country
Employer Name 2/ Address / Position Held (with scale of pay, if in service)
Responsibilities

Continue on the table if necessary

Reference (at least two referee’s ):

May we request a reference? / Before offer of Fellowship / After offer of Fellowship
Name 1
Job Title/Position
Telephone
Address
Email & mobile No.
Please indicate if this is a work reference or an academic reference / Work Reference / Academic Reference
Name 2
Job Title/Position
Telephone
Address
Email & mobile No.
Please indicate if this is a work reference or an academic reference / Work Reference / Academic Reference
Name 3
Job Title/Position
Telephone
Address
Email & mobile No.
Please indicate if this is a work reference or an academic reference / Work Reference / Academic Reference

Project Proposal:

Broad Research Area ( Specify the Focus Area)
(i)Title of the Proposed Project
(ii)Specific area
(i)Objective
(ii)Need / (1000 words maximum)
Commercialization approach / (1000 words maximum)
Milestones (six months each) with relevant deliverables
Envisaged outcome at the end of the project (Technology licensing/ Start up)
Any industry / mentor collaboration
(Is there any already identified partner / mentor? If yes, please provide the details)

Declaration:

I declare that the information I have provided in this application form, to the best of my knowledge and belief, is correct and complete.

If I include any details that you know to be false or if I withhold relevant information, I may render myself liable to disqualification form the recruitment process or, if awarded the fellowship, to withdrawn.

Name of the ApplicantSignature

Date:

Please note:

  • Applicants who are pursuing PhD and have already applied for this fellowship need not apply again.
  • The selected BIRAC Innovation Fellows should work at UIC, Anna University, Chennai.
  • Kindly ensure that all the required information is enclosed. It may not be possible to consider a candidate for want of complete information.
  • This Fellowship is meant for Entrepreneurship Development.
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