Application Form

S.N. BOSE SCHOLARS PROGRAM 2016

  1. Name:

First name / Middle name
Surname
  1. Male Female
  1. Date of Birth (dd/mm/yy):
  1. Passport number:

Country:

Expiration Date:

Date Issued:

If you do not have a passport and have applied for it, mention “Applied For”

  1. Name of the University/Institution:
  1. Address:

Institution / University Address
Residential Address
Telephone / Landline Number # / Mobile #
Alternative Telephone No.
E-mail
Skype id
  1. Major field of study:
  1. Degree program currently enrolled in (e.g., BS, MS, B.Tech., MBBS, M.Tech., Integrated BS/MS):
  1. Cumulative Grade Point Average / Percentage:
  1. 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 / Percent-age/ CGPA/Rank

12. Statement of Purpose: Research interests, possible project ideas and what you hope to gain from this experience (Please restrict your response to the space given below)

13. Research experience, technical background, other internships, courses, lab work, techniques exposed to and past lab experience (Please restrict your response to the space given below)

14. 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).

REFERENCES

(Please furnish details of persons who can provide an assessment of your suitability for this internship)

Details / Reference 1 / Reference 2
Name of Referee:
Designation:
Organisation:
Email id:
Phone number:
Relationship with Applicant

15. Signed and stamped no objection certificate from Parent Institution—This should be given on the official letter-head of the parent institution/organization in the following format:

STATEMENT FROM PARENT INSTITUTION

It is certified that Mr. / Ms……………………….. bonafide B.Tech./ M.Tech./ M.Sc. student is a first/ second rank holder of the ……………(name of the department/institute/ organization), and the institution endorses him/her for the S. N. Bose Scholars Program.

This is to also certify that this institution has no objection to the consideration of application for S.N. Bose Scholars Program from theabove student to undertake a research internship for the duration of 10 weeks at a U.S. university affiliated with the S.N. Bose Scholars Program.

Place & date: (Head of Institution/Organization)

16. 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. 16)

Scanned copy of first and last page of passport

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