APPLICATION FORM FOR

Post Doctoral Fellowship for Women with Break in Career

Department : ______

1. Name / :
Date of Birth (DD/MM/YY) : / Age : / PHOTOGRAPH
Address for Communication: / Permanent Address : / Affix Recent
Passport Size
Photo
Pincode / : / Pincode :
Phone No. : / Phone No:
Mobile No.: / Fax No. :
Email / :

2.Details of University / Institution Studied (Bachelor's level and above)

Sl. / Degree / Discipline / University/College / Year / Average / Class
No. / Marks / CGPA

3.Whether any degree was obtained thro' Correspondence course / distance education mode (Tick therelevant) YesNo(If yes give the details)

…………………………………………………………………………………………………………………………………

4. Professional Experience (Teaching / Research / Industrial )if any:

Name of Organization / Designation / Period / Nature of Work
From / To

5. Publication details (give numbers here and attach list of publications with Title/Year of

Publications etc. in a separate sheet):

International / National
 / Journal Papers
 / Conference Publications

6. Personal Information:

(a)Father's /

Spouse’s Name

(b)Father's

/Spouse’s occupation

(c)Place of Birth

(d)Mother tongue

(e)Nationality

(h)Whether the

applicant isYESNO

employed ?:

(If yes, the application should be submitted through proper channel or NOC from the employer to be submitted at the time of interview)

(i) / Gender / :Male /  Female / 
(j) / Whether SC/ST/OBC: YES /  NO / 

(If yes, enclose the relevant copy of the certificate)

Name of the caste / Sub-caste

………………………………….

(f) / Annual Income / (k) / Whether Physically : YES /  / NO / 
Challenged
(g) / Martial Status / Married  Unmarried /  / (If yes, enclose the relevant copy of the certificate briefly
describe its nature)

I hereby further declare that, I am not employed at present in any Organization / Institute.

………………………………………………………………………………………………………………………………………

DECLARATION

I hereby declare that I have carefully read the instructions and particulars supplied to me and that the entries made in this application form are correct to the best of my knowledge and belief. I understand that association (active or passive) with any unlawful organization is forbidden. If selected, I promise to abide by the rules and discipline of the Institute.

I note that the decision of the Institute is final in regard to selection for admission and assignment to a particular Department and field of study. The Institute shall have the right to expel me from the Institute at any time after my admission, provided it is satisfied that I was admitted on false particulars furnished by me or my antecedents prove that my continuance in the Institute is not desirable. I agree that I shall abide by the decision of the Institute, which shall be final.

Place :

Date :Signature of Applicant

Note :

1)The filled up application form should have the following enclosures:

a)Photocopies of the Rank certificates, Abstract of the Ph.D thesis, any other awards/distinctions obtained, Caste certificate if belongs to SC/ST/OBC, Medical Certificate if Physically Challenged etc.

b)A two page write-up on the intended project work at IITM.

2)The application should be sent to the following address:

The Deputy Registrar (Academic)

Indian Institute of Technology Madras

Chennai – 600 036.

3)All correspondence regarding this scheme is also to be addressed to the respective Heads of department as indicated above.

(For names of the Departments visit: