Application No.
(Not to be filled by the Candidate)
INDIAN INSTITUTE OF TECHNOLOGY ROORKEE
APPLICATION FORM FOR ADMISSION TO Ph.D. PROGRAMMES
1. Separate Application Form should be used for each Department/Centre. Latest
2. Enclose attested copies of all certificates with this Form. Bring original certificates at
the time of Interview/Test and Admission. Photograph
3. Giving false information will lead to cancellation of Admission. (Not to be
4. No column should be left blank. Write Not Applicable against a column if the same
does not apply to you. attested)
5. Tick (D) the relevant box wherever provided.
6. Application incomplete in any respect, is liable to be rejected.
7. Candidates who are in the final year of their qualifying examination can be considered for admission only if they
complete the requirement of their final examination including Viva-Voce before the registration date.
Name of Department/Centre in which admission is sought :
Details of Fee Paid : Draft No. ____________ Dated ____________ Amount ________ Bank Name_____________
Proposed Status Full Time Part Time Sponsored Self Financed
If PART TIME a) Whether working in a project at IIT Roorkee? Yes / No
b) Are you an employee of IIT Roorkee? Yes / No
c) Are you working in a Org./Univ./Inst. Approved by IIT Roorkee as Research Centre? Yes / No
NAME : (in block letters, as given in the qualifying degree certificate)
(IN ENGLISH)
Sex Male Female
Date of Birth Nationality
Father’s Name
Mother’s Name
Permanent Address
Pin Code
Address for Correspondence
Pin Code
Fax No.with STD Code ______________________ Telephone No. with STD Code :
Mobile No. __________________________ e-mail address :
Category : GEN OBC SC ST Foreigner NRI
Do you belong to person with disability (PD) category ? Yes / No
(Reservation for OBC/SC/ST/PD will be as per Govt. of India directive/Institute rules applicable at the time of
admission)
ACADEMIC RECORD
Details of marks/grades secured in the examinations passed.
Examinations SUBJECTS INSTITUTE/ YEAR MARKS/CGPA % of MARKS/
Duration
Course
Passed UNIVERSITY of Max. Obtained CGPA/GPA
of
Passing Marks (Aggregate)
10th Standard
10+2
UG( B.E./B.Tech/
B.Sc./ B.A.)
PG(M.E./M.Tech/M.Sc./
M.A./MCA/MBA)
M. Phil.
Details of Marks/ Grade Point Average secured in the Qualifying Degree Examinations
Name of the qualifying Degree Programme
(M.Tech./M.Sc./B.Tech./B.Arch. etc)
Discipline/ Specialization (e.g. Electrical, Mechanical etc.)
Whether qualifying degree examination Passed (Tick D) Yes / No Year of passing _________________
Details of Qualifying Degree Examination : Name of the University/Institute_____________________________
Semester System
Yearly System
Ist Semester IInd Semester
Year of Study Total
Max. Marks / Marks/Grade Max. Marks/ Marks/ Grade Max. Marks / Marks/ Grade
Grade Secured Grade Secured Grade Secured
Ist Year
IInd Year
IIIrd Year
IVth Year
In case of grade system: GPA/ CGPA _________________________ On a ________________ point scale
In case of marks system: Aggregate Marks Obtained _______ Out of ________ Aggregate percentage_______
Medium of Instruction at Qualifying Examination level : English Hindi Others
(Tick √)
Relevant National Level examination qualified GATE CSIR/UGC NET CEED
Year appeared _________________ Valid Upto ________________ GATE / Other score ______________
Discipline Chosen in GATE/NET/CEED_______________________________________________________________
Awards and Scholarships, if any, _________________________________________________________________
Any other relevant information which you want • Research Experience Years ____ No. of papers published_____
to furnish. • Teaching Experience Years ____ (Attach list giving details)
(UG/PG level)
• Professional Experience Years ____
Whether you were a student at IIT Roorkee previously and discontinued studies? Yes No
If Yes, give particulars of the Name of Academic Programme & Department , Year(s) and the reasons for
discontinuation from the programme______________________________________________________________
Proposed Broad Area of Research (e.g. Civil, Electrical, Physics etc.) ______________________________________
Give Sub-Areas of Proposed research priority wise :
1. ____________________ 2. _____________________ 3. _______________________ 4. _____________________
Write a paragraph on how your qualifications/ experience etc. are relevant to the proposed field of your research.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Employment Record :
Name of Employer(s) Period of Employement Designation & Salary Nature of Duties
Employed candidates seeking admission as full time / part time / sponsored category must submit
Application Form through their employer on the proforma given below.
NO OBJECTION / SPONSORSHIP CERTIFICATE
(Required from Full Time / Part Time / Sponsored candidates only)
The undersigned is pleased to sponsor Mr./ Ms. ............................................................................................ who
is working in this organisation for the last ....................... years and is presently holding the rank/ position of
.............................................. for pursuing Ph.D. programme in the Department of
................................................................................................................... with specialisation in the following areas
1. .................................................... 2. .................................................... 3. ....................................................
His/ Her conduct and character is good.
The Institution/ Organisation would allow/relieve him/her immediately for joining the above course, if selected for admission.
The Institution/ Organisation also agrees to PAY/ NOT PAY the contingent/ all expenses stipulated by the Institute. This
is further certified that the sponsorship for admission will not be withdrawn midway till completion of the Ph.D. programme.
Place : ............................................. Signature of the Head of the Institution/ Organisation with seal
Date : .............................................. Name ..........................................................................
Designation .....................................................................
UNDERTAKING
I, ...................................................................S/o/D/o.....................................................................
hereby undertake to abide by rules and regulations in vogue from time to time, and shall not indulge in any
act of indiscipline. The factual information given by me are correct.If at any time the information provided by
me is found to be incorrect, my admission be cancelled.
Date Signature of Candidate
Check List
i) Attested copies of the qualifying degree/ certificate and marks sheet showing the required % of marks/CGPA.
ii) Proof from the University/Head of the Institution of having appeared/passed in the qualifying Degree Exam.
iii) Attested Copy of GATE Score Card and its Admit Card /Equivalent National Test certificate.
iv) Attested Copy of SC/ST/OBC/PD certificate.
v) Certificates pertaining to No Objection/ Sponsorship on the proforma of the Application Form.
Note : Original Certificates will be required for verification on at the time of registration by the Institute.
