1

Application no (for office use only):

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INSTITUTE OF LIFE SCIENCES,
BHUBANESWAR
(An Autonomous Institute under the Department of Biotechnology, Govt. of India)

Application for Ph.D. programme


1. Full name:
2. Name of Father/Husband:
3. Gender: Female/Male 4. Date of birth:
5. Marital status:
6. Address for correspondence:



7. Permanent address:



8. Telephone no.: 9. Mobile no.:
10. Email:
11. Category: General/SC/ST/OBC (mark as applicable)
12. Physically handicapped: Yes/No
13. Details of demand draft (DD no., Issuing Bank and Date):
14. Details of national examinations (CSIR/UGC, ICMR, DBT, DST-INSPIRE, DBT-BINC,
GATE)
Sl. No Name of the
examination
Award letter no.
& Date
Roll no. Fellowship
(Yes/No), If
yes, valid upto














Self-attested
photograph
(3.5 X 4.5 cm)
2

15. Educational qualification:
Qualification Board/ University Year of
Passing
Subjects % of
marks/
CGPA
Bachelors
degree


Masters
degree



16. Title and duration of Masters project (if any):






17. Check list of enclosed documents:
Sr. No. Document description Tick here
1. Masters degree mark sheet
2. Bachelors degree certificate
3. Age proof (Class X) certificate
4. SC/ST/OBC or PH certificate (if applicable)
5. National examination qualification certificate


Declaration:

I declare that the information furnished in this application form is true in all aspects and I
understand that in case any entry or information is found to be false, my admission shall be
cancelled/terminated.



Place:
Date: Signature

General instructions:

1. Please fill up the form with BLACK ink and in CAPITAL letters.

2. Demand draft of Rs. 500/- should be drawn in favour of the Director, Institute of Life
Sciences, Bhubaneswar and payable at Bhubaneswar.

3. Incomplete forms will be rejected.