APPLICATIONFORMFORVITERBIINDIAPROGRAM

1. Name:
Firstname
Surname

Middlename

2. MaleFemale
3. DateofBirth(dd/mm/yy):
4. Passportnumber:
(ifapplied,referencenowithtentativedateofreceivingthepassport)
5. NameoftheUniversity/Institution:
6. Address:

Institution /
University Address
Residential Address
Landline Number #

Mobile #

Telephone
Alternative
Telephone No.
E-mail

7. Majorfieldofstudy:
8. Degreeprogramcurrentlyenrolledin(e.g.,BS,MS,B.Tech.,M.Tech.,
IntegratedBS/MS):
9. CumulativeGradePointAverage/Percentage:

10. ExpecteddateofGraduation(CompletionofDegree):____(mm)____(yy)

11. Tentative/likely date for the completion of the final examination in 2017:

12.AcademicRecord:
EDUCATIONAL QUALIFICATIONS (10th Standard onwards)
Examination/
Degree

University/
Board

Duration
(from
mm/yy to
mm/yy)

Institute/
College/
School

Subjects studied/
Specialization

Percentage/
CGPA/
Rank

13.Researchinterestsandpossibleprojectideas.Pleasevisit
http://viterbi.usc.edu/summerinternshipandViterbiSchoolfacultywebpagesand
list23facultymembersyouwouldbeinterestedtoworkwith.
(Pleaseattachaseparatesheetifthespaceisinsufficient).

14.Researchexperience,technicalbackground,otherinternships,courses,lab
work,techniquesexposedtoandpastlabexperience.
(Pleaseattachaseparatesheetifthespaceisinsufficient).

15.Careergoalsandwhatyouhopetogainfromthisexperience.
(Pleaseattachaseparatesheetifthespaceisinsufficient).

16.References(Oneoftherefereesshouldbeyourteacher/tutor.Incaseyouhave
completedatraining/internshipinanylab,areferencefromyoursupervisorthere
wouldbepreferred.Thereferencesshouldbeprovidedontheofficialletterheadsof
theRefereesandcanbeemaileddirectlytoviterbiindia@indousstf.org).
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
Organisation
Designation
Relationship with Applicant
Email id
Phone number #

17.SignedandstampednoobjectioncertificatefromParentInstitutionThis
shouldbegivenontheofficialletterheadoftheparentinstitution/organizationin
thefollowingformat:
STATEMENTFROMPARENTINSTITUTION
Thisistocertifythatthisinstitutionhasnoobjectiontotheconsiderationofapplication
for the ViterbiIndia Program from Mr./Ms ..bonafide B.Tech./
M.Tech./ M.Sc. student in the (name of the department/institute/
organization)toundertakeresearchinternshipattheUniversityofSouthernCaliforniafor
adurationof8weeks.

Place&date:(HeadofInstitution/Organization)

18.SupportingDocumentationchecklist:
Currenttranscript(LatestMarkssheet)
Twolettersofrecommendationfroma
facultymember,advisororlabsupervisorontheirofficialletterhead
NoobjectioncertificatefromParentInstitution
7

(intheformatprovidedinS.No.15)