Application No

Ph.D. REGISTRATION FORM Affix Recent

Color
1. Name (in Block Letters) : …………………………………….. Passport Size
Photograph

2. Sex : Male / Female

3. Address

(a) Official (with Designation) : …………………………………………………………………...

…………………………………………………………………..

…………………………………………………………………..

…………………………………………………………………..

(b) Residential : …………………………………………………………………...

……………………………………………………………………

……………………………………………………………………

……………………………………………………………………………

(c) Contact Phone Number

i) Residence (with STD Code) : …………………………………………………………………..

ii) Office (with STD Code) : …………………………………………………………………..

iii) Mobile : …………………………………………………………………..

(d) E-Mail Address : …………………………………………………………………...

 4. Date of Birth &Age : …………………………………………………………………..

5. Nationality : …………………………………………………………………...

6. Social Status : ST/SC/OBC/BC/OC/PH

7. Community : …………………………………………………………………………………………………….

8. Category : a. Full Time

: b. Part Time (Internal)

: c. Part Time (External)

9. Are you employed? : Yes /No

If yes specify the

Name and Address
of the employer

10. Salary received / Month : …………………………………………………………………..

Processing Fees Details

Amount Cash/DD No Cash/DD Date Bank Name

10. Academic Background (Start with the latest Degree Obtained)

(Enclose copies of Degree/Diploma certificates duly attested)

Sl.No Degree/Diploma Year of University/Institution Major Percentage

passing Discipline of Marks
and Class
obtained
11. Professional Experience (Start from the present employer)

Sl.No Organization Period Designation Total Nature of

From To salary/Month Job

12. Publications, if any (Books / Research Papers) :

Sl.No Title Name of the ISSN/Impact Year

Journal/Conference/Published in Factor/Scopus
the case books

13. Awards/Medal/Prizes and Honours

Conferred (if any) : …………………………………………………………………..

14. Major area of Ph.D Research : …………………………………………………………………..

15. Tentative Topic on which the research : …………………………………………………………………..

is proposed to be conducted
(Attach one-page write up on this topic)

16. Department in which the candidate : …………………………………………………………………..

Propose to register

17. Name and Designation of the : …………………………………………………………………..

Research Supervisor

18. Signature of the Research Supervisor : …………………………………………………………………..

with Designation

19. Name, Designation & Address of the : …………………………………………………………………..

Research Coordinator (Outside the University)………………………………………………………………….
For Part Time (External) Candidates only ……………………………………………………………………

Note: Part-time (external) candidates shall have a supervisor at SMVEC and in addition, shall have a
Research Coordinator at the organization in which they are working.
 20. 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.

Place :
Date :
Signature of the candidate

Signature of the Head of the Department/Institution Signature of the Head of the Institution

(where the candidate is working) (where the candidate propose to conduct Research)