Indian Institute of Science Education and Research Bhopal

(Last date for receiving the application is _______/________)

Application Form for Winter Internship starting on December 2, 2019)

1. Full Name (Ms/Mr): ………………………………………..

2. Date of Birth: …………..………………………..
3. Name of Degree being pursued:……………….(Specify degree and subject)
Year of study: From: ……………………….To:…………………….
4. Name of the faculty contacted for winter training/internship in
IISER Bhopal:…………………………………………….
5. Dates of internship proposed: From………...…….To:………………
6. Address for Correspondence:…………………………………………………
………………………………………………………………………………..
Phone No……………………………Fax No………..……email:…………..
7. Do you require hostel & mess facility: Yes/No:…………………
8. Educational Details: Enclosed attested copies of mark/grade sheets:
Degree/ College/ Univ/ Year Class % marks Rank Subject
Exam School Board or grade in class
UG

PG

Others
(if any)

9. Area of research interest: …………………………………………………

10. I certify that the information above is correct. If selected for internship at IISER
Bhopal, I agree to abide by all rules and regulations of IISER Bhopal and pay the
required fees.

Signature of Candidate
11. Endorsement:
I certify that (Ms/Mr.)………………………………………………..is a student of
………….(degree) studying in ………year in our college/University/ Institute and internship
of ………………………days/months in IISER Bhopal will be beneficial for her/his studies.

Date: Signature of Head of the

Place: Department /Principal/Director

For IISER Bhopal use only

Recommendation of Guide:…………………
Supported by project, Yes/No……………If yes Project No…………………..……

Name & Signature of Faculty Member Name & Signature of HOD

Guide

Internship Approved/Not-Approved Dean, Academic Affairs

Guidelines:

1. The period of winter internship will be between December 2, 2019 and December 29,
2019 or as per winter recess.
2. No financial assistance will be provided. Mess will be charged as per actual rates,
payable to the mess contractor.
3. Institute does not guarantee for any hostel accommodation which is subject to
availability only. If hostel is allotted, Rs. 1500 will be charged as hostel rent and Rs
1000/- will be charged towards water & electricity charges. This is subject to
revision from time to time.
4. After successful completion of internship, certificate will be issued by Faculty In-
charge.