Professional Documents
Culture Documents
1.
Full Name :
2.
Date of Birth:
5.
Marital Status:
7.
Fathers Name:
8.
Address of Correspondence:
3. Place of Birth:
Paste your
photograph
here
4. Gender: Male/Female
6. Nationality :
11. Department/Programme
12. Admission for Degree
13. Student Status
State:
Pin Code :
14. Financial Status
9. Contact Details:
Phone No. :
15. Category
Mobile No. :
E-mail address :
Yes / No
Exam Name
Exam Year
University
% Marks or
Grade Average
Discipline
Degree
Exam Date
Sem. I
Sem. II
Sem. III
Sem. IV
Sem. V
Sem. VI
Sem. VII
Sem. VIII
Final
results
expected
by
Pass
Marks %
or Grade
Average
Overall % or
Grade Average
(if degree completed)
C. Other Degrees obtained after 10+2 (Do not include the degree listed in 17 B)
Institute/ College
University
Discipline
Degree
Marks or
CPI
Date of
completion
D. Working Experience
Dates (from-to)
Employer
Position
Published in Journals
Nature of Work
Presented in Conferences
Pref. 1
Pref. 2
Pref. 3
Pref. 4
19. Names and addresses of two referees from whom letters of reference have been obtained (For Ph.D. applicants only)
1.
2.
Date :
Signature :
INSTRUCTIONS
FOR
F ILLING
THIS
FORM
1.
This form is to be used for applying to all Departments and IDP, excepts PHYSICS & CHEMICAL Engineering Departments as they
are not offering admission in the Ph.D. in December semester.
2.
3.
Go through the codes for Items 11-15 given below, and fill them carefully in the boxes on Page 1.
4.
The application fee of Rs. 400/- for candidates in General/OBC and Rs. 200/- for SC/ST/PD must be paid through demand draft
payable to The Registrar I I T Kanpur at Kanpur
Date of Birth (DOB) Certificate or High School (Class Te n) Certificate with DOB
2.
SC/ST/OBC(NCL) Certificate, if applicable (Item 15). Certificate format is given on the website.
3.
Certificate of Physical Disability, if applicable (Item 16). Certificate format is given on the website.
4.
5.
6.
7.
No Objection Certificate from employer (only for part-time/external) (Item 13). Full time students currently working must
produce NOC or Relieving Certificate from the employer at the time of admission.
8.
The Demand draft for the application fee of Rs. 400/- or Rs. 200/- as applicable
9.