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Appln.

No:
For office use only
ANNA UNIVERSITY OF TECHNOLOGY MADURAI
Alagar Koil Road, Madurai – 625 002
APPLICATION FOR ADMISSION TO RESEARCH PROGRAMME – JANUARY 2011
Ph.D. M.S. (By Research) (Tick whichever is applicable)
Affix recently
taken passport
1. Name (in Block letters with size photo
Initials at the end) :

2. Sex : Male/Female

3. Nationality : Indian/Foreign

4. If foreign national : Country____________ Passport No___________


5. Social Status : ST/SC/ SCA/MBC/BC/BCM/OC

6. Community :

7. Age & Date of Birth :

8. Marital Status : Married/Unmarried

9. Email Address :

10. Address:
Office Address Residential Address:
Designation :
Organization :
Place :
Taluk/Dt./State :
Pincode : Pincode :
Phone : Phone :
Fax : Fax :
Mobile : Mobile :

11. Category applied for: (Tick appropriate box, after referring Instructions)

FULL TIME PART TIME

Note: The candidates working in University Departments / Constituent Colleges / Affiliated


Engineering Colleges of Anna University of Technology Madurai situated in the districts of Madurai,
Sivagangai, Dindigul, Ramanathapuram and Theni only are eligible to apply under part time category.

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12. Details of Current employment (if Applicable)
Name & Address of the employer :

Nature of employment : Regular/ Approved Probationer/Consolidated


Pay/Contract/Visiting Nature /Part Time /
Temporary/TRA

Scale of Pay:_____________________________ working since (date):____________________


(Certificate from the employer to be attached)

13. Details of employment in project (if applicable)

Name of the principal Investigator:__________________________________________________


(copy of the project sanction order to the principal investigator should be enclosed)
Title of the project:
_____________________________________________________________________________
Funding Agency :_________________________ Duration of the Project: __________________
Stipend:____________working since date___________ Project completion date:_____________

(Copy of the project staff appointment order should be attached)

14. Academic Background:


(Enclose copies of Degree/Diploma Certificate duly attested from the latest degree obtained)

Major % of Regular/Part
Sl. Degree/ Year of Class
College University Discipline/ Marks/ time/ others
No Diploma passing Obtained
Specialization CGPA (specify)
1.
2.
3.
4.
5.

15. Professional Experience (Start from the present employment)


Period Total
Sl. Salary Nature of
Organization Designation
No From To (per Job
Month)
1.
2.
3.
4.

16. Details of Publications in referred journal :


(if any, photocopy shall be enclosed)

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17. Major area for Ph.D./M.S(By Research) Degree Programme :

18. Tentative research topic :


(One page write-up of proposed research with signature of
Candidate & Supervisor should be enclosed)
19. i) College in which the candidate proposes to register :

ii) Department in which the candidate proposes to register :

iii) Faculty : CIVIL / MECH /


ELECTRICAL / I&C /
TECH / S & H /
MANAGEMENT
20. Name, Designation and Address of the proposed
a) Supervisor :

b) Joint Supervisor (applicable only for candidates from :


industry / research organizations recognized as a
research centre by this University)

21. D.D Particulars: (Rs.600/- for General Candidates(Rs.300/- for SC/ST Candidates) drawn in favour of
“The Director, Centre for Research, Anna University of Technology Madurai”, payable at Madurai.)

Name of the Bank & Branch Demand Draft No. Date Amount

22. Awards, Medals, Prizes and Honors conferred if any :

DECLARATION OF THE CANDIDATE

This is to certify that the particulars given above are true, correct and complete to the best of my
knowledge and belief. I am aware that any wrong information or suppression of information and facts may
result in punitive action in addition to cancellation of my candidature for Ph. D. / M.S. (By Research)
programme admission.

Place:
Date : Signature of Candidate

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CONSENT OF THE SUPERVISOR / JOINT SUPERVISOR
(Recognized supervisors working in the recognized departments shall only function as supervisor)
SUPERVISOR*
JOINT SUPERVISOR
(should furnish the
(Applicable only for candidates from
University Ref. No. for
Industry / Research Organisations
Supervisorship
Recognized by this University)
Recognition)
Name

Designation

Nature of Appointment

Department
College / Organization
Address
Date of Birth

Area of Research

Whether the supervisor


YES / NO
fulfils the norms as per YES / NO
If Yes, please furnish
Ph.D. / M.S. (By Research) If Yes,please furnish University Ref. No.
University Ref. No.
Regulations
No. of Research Scholars Ph.D. M.S. Ph.D. M.S.

As on Date

As Supervisor

As Joint Supervisor

Total

Signature

* The supervisor while giving his / her consent should furnish the list of panel members for DC / MC in the
enclosed format (page 5). A Supervisor shall not normally guide more than ten research scholars
(including MS by Research Scholars) for Ph. D. at any time. Additional candidates, if any under
extraordinary circumstances, shall be decided on the merit of the cases, subject to the approval of
Research Board.

Joint Supervisor is mandatory if the supervisor is not regular faculty member of this university. A
maximum of ten research scholars only be permitted under such supervisors.

If the supervisor wants to guide in areas other than his / her area of research, these areas shall be
accepted based on two publications in reputed journals or the staff member shall have handled PG level
classes in the above areas, during last three years preceding the date of application.

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CENTRE FOR RESEARCH
ANNA UNIVERSITY OF TECHNOLOGY MADURAI, MADURAI – 625 002
LIST OF PANEL MEMBERS FOR DC / MC
[To be sent in a sealed cover]
Ph.D. M.S. (By Research) (Tick whichever is applicable)

Name of the Candidate :


Research Topic of the Candidate :
(Abstract of topic duly signed by the
Supervisor should be enclosed)
Name of the Supervisor :
Supervisor Recognition Ref. No. :
Sl.
Name with full address Area of Research in Ph.D.
No.
From Academic Institutions:
1. Name :
Designation :
Department :
Address :

Mobile : Email:
2. Name :
Designation :
Department :
Address :

Mobile : Email:
3. Name :
Designation :
Department :
Address :

Mobile : Email:
From Industry/R&D organizations:
1. Name :
Designation :
Department :
Address :

Mobile : Email:
2. Name :
Designation :
Department :
Address :

Mobile : Email:
3. Name :
Designation :
Department :
Address :

Mobile : Email:

SIGNATURE OF THE HOD* SIGNATURE OF THE JOINT SUPERVISOR SIGNATURE OF THE SUPERVISOR
(NAME WITH ADDRESS) (NAME WITH SEAL) (NAME WITH SEAL)
*HOD of the Supervisor (if applicable)

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