CSIR- INSTITUTE OF MINERALS AND MATERIALS TECHNOLOGY (Formerly Regional Research Laboratory

)

Council of Scientific & Industrial Research
BHUBANESWAR – 751 013

Tel (PBX): 0674-2581635/36/38/39, Fax : 91-674-2581160, E-mail: pgdme@immt.res.in, Website: www.immt.res.in

Application form for admission to

One Year Post Graduate Diploma in Mineral Engineering
(Academic Year 2012-13) DD Particulars DD No.: ………………….Date:………………… Amount:…………………..Bank:…………………… 1. Name: (Full and in Block Letters) 2. Mailing Address: (In Block letters) For Office Use Application No.:……………….. Receiving Date:…………………

Pin Code:………………… Fax: 3. Permanent Address: (In Block Letters) E-mail:

Please paste self signed recent colour passport size photograph

Phone:

Fax: 4. Nationality :

E-mail:

Phone:

5. i. Date of Birth (dd/mm/yyyy) …………./………/…….. ii. Age as on 1st June 2012 ……………Years ………………..Months 6. Knowledge in English Language: Spoken : YES / NO Written : YES / NO

Whether Hostel Accommodation Required: 9. GATE / NET Score. if received 12. please enclose a certificate from your organization) ii. Scholarships / Awards / Prizes etc. Are you sponsored by your Company for this course (If yes.7. Whether SC/ST/OBC (Non-creamy): Certificate to be attached 8. Record of Academic/Technical Training: School/College/ University YES / NO (Commencing from Secondary School Certificate or Equivalent Examination* Examination Principal Subjects Class/ Division Year of Passing % marks scored (Grade Points) * Please enclose attested true copies / photocopies of certificate and marks sheets 10. i. Name and address of the Sponsor: YES / NO . Employment Record / Professional Experience* Nature of Business/ Product Period of Employment From To Designation & Responsibilities Name and address of the Company / Employer * Please enclose proof of your employment experience 13. if any: 11.

4. 3. f) Any legal dispute arising out of the admission to this course will be under the jurisdiction of appropriate courts of Bhubaneswar only.14.res. vii.in) d) The application should be printed. INDIA with application fee and other enclosures. [in addition to the one on application] 2. (E-mail: pgdme@immt. Colour photograph (passport size) . vi.1 no. iv. Sponsorship certificate for sponsored candidate. DD towards application fee. Bhubaneswar-751 013. INDIA. PG Diploma in Mineral Engineering. Any other information: 15.2012. s hould at once be communicated to t he Program Coordinator. 500/-(Rs 250/. given in col. v. Caste certificate for reserved non-sponsored candidate. Viii. List of enclosures to be attached: 1. ii. b) Last date of receipt of application is 15. Date: Place: Signature of Candidate Note: a) INCOMPLETE APPLICATION WILL NOT BE ENTERTAINED. I hereby agree to abide by the Rules and Regulations of the course framed by IMMT. duly filled and sent to th e Program Coordinator. the application will not be considered.06. Bh ubaneswar-751 013. Mineral Processing Department. IMMT (F ormerly RRL). If the ap plication is not rec eived on or b efore the stipulated date. IMMT (Formerly RRL). payable at Bhubaneswar should be sent along with the application. 2. List of enclosures: i. Mineral Processing Department. c) Any change of address. Photo copy of certificates and mark sheets from HSC (10th) on wards. 5. e) Application fee of Rs. iii.for SC/ST under non sponsored category) in the form of DD drawn in favor of PG Diploma in Mineral Engineering. DECLARATION I declare that the above information furnished by me is true to the best of my knowledge and belief. PG Di ploma in Mineral Engineering. . If selected.