APPLICATION FORM FOR PROJECT WORK/TRAINING

PROGRAMME at CSIR- IMMT

1. Name : Tapas Rout

2. Address of Correspondence (Email Address & Telephone no.): email:tapasroutvss@gmail.com
3. Certificate of HOD of the Department/ Institute for permission to carry out Dissertation
work in our Institute - (Attached)- Y/N:Y
4. Address of the Institute : Veer Surendra Sai University of technology
5. Basic subject in which dissertation work proposed to be carried out: Plastic electronics
6. Date of Birth: 31/07/1994
7. Educational qualification*BTech(3rd)
1. Secondary Education:
Name
of
Exam.

Year of Division Marks/ Subject

passing
Grade

Institute from
which passed

University/
Board

2010

Bhavan Varuna
Vidyalaya,kochi

CBSE

9.8

93
English,Hindi,Maths,Socia
l Science,Science

2. Higher Secondary Education:

Nam
e of
Exa
m.

Year Divisio Mark Subject

of
n
s/
passin
Grad
g
e
2012
87
Biology,Chemistry,Physics,English,
Maths

Institute from
which passed

Universit
y/ Board

DAV School
Chandrasekhar
pur

CBSE

3. Graduation Degree:
Name of Exam.

Year of
passing

Division
Hons
Distinction
(Y/N)

HRD, CSIR-IMMT Page 1

Marks/
Grade
Hons.

Subject

Institute from
which passed

University/
Board

(Continue)

4. Graduation Degree (Engineering):

Name of Exam. Year of
passing
1st semester

Division

Marks/
Grade

Subject

Institute from
which passed

University/
Board

Division

Marks/
Grade

Subject

Institute from
which passed

University/
Board

Division

Marks/
Grade

Subject

Institute from
which passed

University/
Board

2nd semester
3rd semester
4th semester
5th semester
6th semester
7th semester
8th semester
5. Master Degree (Engineering):
Name of Exam. Year of
passing
1st semester
2nd semester
3rd semester
4th semester
GATE score

6. M.Sc.
Name of Exam. Year of
passing
1st semester
2nd semester
3rd semester
4th semester

HRD, CSIR-IMMT Page 2

* Fill up the relevant information only.

* Hard copy addressed to "Convenor- HRD", CSIR- IMMT, P.O-RRL, Acharya Vihar,
Bhubaneswar-751013. The envelope must be superscribed with the Name of the
Discipline/ Branch.

Mandatory Requirements:
Attach photocopy of following documents:
Approval/Forwarding letter from HOD/ parent Institution
Marksheet from 10th onwards.
Pass certificate from 10th onwards.

o Application will be rejected under following conditions:

Incomplete application.
Non submission of relevant documents.

Signature of the Applicant

HRD, CSIR-IMMT Page 3