भाररतीय पर्ौ

पर् ोििगकी सं
सस्थान
न पटनाा
INDIA
AN INSTIITUTE OF
O TECHNOLOG
GY PATN
NA

 
F
FORM FOR
R SUMMER
R INTERNS
SHIP PROG
GRAMME AT IIT PA
ATNA – 20__
__
Perssonal Inforrmation
Namme:
Date of Birth: Gender:
Corrrespondencce Address::
otograph
Pho
Phoone No.: e-mail:
Is an
ny disciplin
nary case peending agaiinst you?: Yes/ No
o
(If yees attach detaiils in separatee sheet)

Pare
ents’/Guard
dian’s conta
act informaation
Namme Rela
ation
Adddress

Pho
one No. Mo
obile No.
e-m
mail

Insttitute affiliaation inform

mation
Namme of Institu ution
Adddress
Deg
gree /Programme Semeester/year
CGP
PA/Marks %:

Reference
Nam
me
Add
dress

E-m
mail Ph No. Fax No.
N

Dep
partment att IIT Patna
Dep
partment of applicationn at IIT Patn
na
Sup
pervisor(s) Name
N
Reseearch Topicc/Area

Durration of staay at IIT Pattna

Hosstel accommmodation is required?

I heereby declarre that all in

nformation given
g abovee is I herreby consen
nt to superv
vise the stud
dent for the
corrrect. duraation mentiooned abovee.

nature with Date

Appliicant’s Sign Superv
visor

Thee student is selected as summer inttern under supervision

n of Prof. /D
Dr. ..........................................................

H.O.D)
(H
 INDIAN INSTITUTE OF TECHNOLOGY PATNA
Kanpa Road, Bihta, Patna-801103, Bihar, INDIA
Ph.: + 91-612-3028101
Fax: + 91-612-3028383

Declaration to be submitted by Project Trainees

The undersigned do hereby declare that:

1. Mr/Mrs/Ms. ……………… , So/Do/Wo……………..is a ……………..(class/batch)

regular student of ...................(name of Institute)

2. He/ She is being permitted to undertake ………………semesters (time) project work at

IIT Patna from …………(date) to ……………….(date).

3. The right of intellectual property generated as an outcome of this project will lie
equally with both the institutes.

4. Mr/Mrs/Ms. ……………..(name of the student) will abide by all the rules and
regulations as well as adhere to the discipline of IIT Patna.

5. Mr/Mrs/Ms. ……………..(name of the student) will follow the ethical practices in

his/her conduct during the entire period of stay in IIT Patna.

Signature of Student: Signature of /HoD/ Head of Institution:

Name : Name :
Address: Department:
Contact No.: Date:
Local Guardian(if any):

Signature of the Supervisor

Name:
Designation:
Department:
IIT Patna