WADIA INSTITUTE OF HIMALAYAN GEOLOGY

(An Autonomous Institute of Deptt. of Science & Tech., Govt. of India)

33, General Mahadeo Singh Road, Dehra Dun - 248 001

Application form for Dissertation Work / Summer Training

2022
(Please tick the right choice)

1. Full Name (in Block letters):

Affix recent passport
size colour
photograph duly
singed
2. Father's/Husband's Name:

__________________________________________________________________________
3. (a) Address For Correspondence (b) Permanent Address
(give phone and e-mail address also) (give phone and e-mail address also)

E.mail:

Phone No.:

4. Date of birth & Place of birth:

Age on the date of this application: Years Months Days

5. a. Sex: Male / Female :

b. Marital Status :

c. Identification Mark :

6. Nationality :
Contd... on page2/-
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7. (a) Whether Scheduled Caste/Scheduled Tribe/OBC ?

(b) If yes, please state category:

(Please enclosed attested copies of documentary evidences)

8. Academic Qualifications:
(Commencing from High School or an equivalent examination)

Examination/ Subject/ Year Division % University Distinctions/

Degree Specialization Marks/ /College/ Scholarships
Grade Board

9. Have you been punished during your studies at College/university?

(If so, give details)

10. Prizes/ Medals / Awards / Honours, if any

11. Special Training/Assignment/ Any other Relevant Particulars:

12. Statement of Research Interest:

(Please attach 100-150 words write-up of your research interest)

Contd... on page 3/-

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13. Declaration to be signed by the candidate

I hereby declare that the entries in this form are true to the best of my knowledge and
belief. If at any time I am found to have concealed any material information or given any false
details, my application shall be liable to be summarily rejected without notice.

Dated:
Signature of applicant

Forwarding by Head of the Department/Institution/Organization

Forwarded with the remarks that the applicant is a bonafide student of

………………………..department of the ………………………………………………..
university/research institute/college, and information provided above is correct to best of my
knowledge. The organization has no objection to the candidature of the applicant for the
summer training at Wadia Institute of Himalayan Geology, Dehra Dun.

Dated:
Signature
(Head of the Department/Institution/Organization)
Designation
Address:
Telephone/Fax No. (with STD Code)

Office seal