FT PT Ph.D.

FT PT M.Phil

Accredited by NAAC with A Grade

MHRD A Category University

Recognised Research University

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Application for Admission to M.Phil. / Ph.D. programmes offered at

Visakhapatnam, Hyderabad and Bengaluru Campuses for the year 2015 2016

PIN or STAPLE

(Mark)

Last Date: 31st July 2015

1. NAME OF THE APPLICANT : (AS PER CLASS X OR EQUIVALENT MARKS MEMO)

2. DATE OF BIRTH 3. GENDER ( Mark )

DATE MONTH YEAR MALE FEMALE

4. CATEGORY ( Mark ) :

OC

SC

ST

PH

OTHERS

5. NATIONALITY

6. NAME OF THE PARENT / GUARDIAN:

7. ADDRESS FOR CORRESPONDENCE (DO NOT REPEAT NAME):

STATE : PIN CODE :

8. STD CODE PHONE NO. MOBILE NUMBER

9. RESEARCH PROPOSED TO BE CARRIED OUT IN FACULTY

DEPARTMENT:

AREA OF RESEARCH

SPECIFIC TOPIC OF RESEARCH

10. PARTICULARS OF QUALIFYING EXAMINATION:

Qualifying PG / M.Phil. Degree

Specialization % Marks Class University Year of Passing

(PTO)

- 2 -

11. WHETHER QUALIFIED IN NET / GATE / GPAT: YES / NO

IF YES INDICATE TEST DATE AND SCORE:

12. FOR CANDIDATES APPLYING FOR M.PHIL. / Ph.D. PART-TIME:

i) NAME OF THE INSTITUTE WHERE THE CANDIDATE IS AT PRESENT WORKING:

ii) DESIGNATION

iii) TOTAL YEARS OF SERVICE TEACHING INDUSTRY RESEARCH

Iv) WHETHER NO OBJECTION CERTIFICATE FROM THE PRESENT EMPLOYER IS ENCLOSED: YES / NO

13. FOR CANDIDATES APPLYING FOR M.PHIL. / PH.D. UNDER INTERDISCIPLINARY

i) NAME OF THE FACULTY AND DEPARTMENT WHERE MAJOR PART OF THE WORK IS PROPOSED TO BE CARRIED OUT:

FACULTY DEPARTMENT

II) NAME OF THE FACULTY AND DEPARTMENT WHERE THE REMAINING WORK IS PROPOSED TO BE CARRIED OUT:

FACULTY DEPARTMENT

14. FOR CANDIDATES APPLYING FOR Ph.D. UNDER EXTRAMURAL RESEARCH:

i) NAME OF THE ORGANISATION IN WHICH THE CANDIDATE IS AT PRESENT WORKING:

ii) DESIGNATION iii) TOTAL YEARS OF SERVICE

iv) NAME AND DESIGNATION OF THE RESEARCH GUIDE FROM THE PARENT ORGANIZTION (OPTION):

v) WHETHER BIO-DATA OF THE RESEARCH GUIDE ENCLOSED: YES / NO

vi) WHETHER NO OBJECTION CERTIFICATE FROM THE PRESENT EMPLOYER IS ENCLOSED: YES / NO

15. DETAILS OF REGISTRATION FEE:

DD NUMBER DD DATE DD AMOUNT ISSUING BANK

` 3000

Note: Please enclose the Demand Draft along with the Application. Mention your Name on the reverse of Demand Draft.

DECLARATION: I hereby declare that all the particulars stated in this application are true to the best of my knowledge and belief.

I shall abide by the rules and regulations of GITAM UNIVERSITY. In the event of submission of incorrect or untrue information at

the time of registration or in future, I understand that my admission is liable for cancellation. Further I understand that my

admission is purely provisional and subject to the fulfilment of the eligibility conditions. I agree to receive SMS on my mobile from

GITAM University.

SIGNATURE OF THE PARENT/GUARDIAN SIGNATURE OF THE APPLICANT