VISVESVARAYA TECHNOLOGICAL UNIVERSITY,

BELGAUM, KARNATAKA

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attested by Principal
/ Head of College /
University
last
attended
or
a
Gazetted Officer

APPLICATION FORM FOR PHD/ M.Sc. (Engg) BY RESEARCH

FOR THE ACADEMIC YEAR 2013-14
Full time

Part time

Programme Applied for: Ph.D.

Research Centre applied for: VTU-RC

Faculty Applied for : Engineering

Category : GM
Male

SC

ST

VTU-R&D
Architecture

VTU-RRC

Science

CAT-I

M.Sc.(Engg)

Computer Applications

Physically Challenged

Female

Married

Business Administration

Others
Unmarried

Name: ......Date of Birth:....

Fathers Name:..
Academic Qualification:
Programme
Degree
University
Regular
Specialization
% Marks obtained
obtained
/Distance
with Class
UG

Year of
passing

PG
M.Phil
Others if any
No. of years of experience: Industry:

Teaching:

Research:

Number of Research papers:

Patents:

Awards:

Topic of Research proposed:

Titles of the proposed course work (enclose detail syllabus in separate sheets)*
SL.No

Group

Code

Subject

1
2
3
4
5
6
7
8
*For details refer clause 14.1 & 14.3 of Ph.D. New Regulation

Research Centre
1. VTU-RC: .Department:....Recognized: Yes

No

2. VTU-R&D: Department:.....Recognized: Yes

No

3. VTU-RRC: Belgaum. Department..

Application and Processing Fee Details: D.D. for `. 800/- No.:Drawn on Bank...date:.

Information of the Supervisor

Name: Date of Birth...
Affiliation : Department:
DesignationArea of Research
Academic Qualification:
Programme
Degree
obtained
UG

University

Regular
/Distance

Specialization

% Marks obtained
with Class

Year of
passing

PG
Ph.D.
Others if any
No. of Publications in the preceding 5 years:
Research papers: 1. National Journal

communicated: 1. National Journal

2. International Journal
Conference:

1.

Technical Reports:

2. International Journal
Book:

Patents:

Awards:

No. of students Supervising:

Sl.
No.

Programme
Please tick (
)

Name of the
Candidate/s

Ph.D.

University

Category

Specify
Whether
Final Thesis
Year of whether acting
Area of
registration as Supervisor Specialization Submitted
or
(Y/N)
Co Supervisor

M.Sc.
(Engg)

1
2
3
4
5
6
7
8
Total

Undertaking from the Supervisor

I, is a permanent faculty /employee working as . in
the Department of . in the organisation .......and
is

aged

less

than

62

years

as

on

the

date

of

admission

notification,

hereby

certify

Mr./Mrs....registering for ..... degree under

that

the

candidate

VTU is not

my

son/daughter/immediate blood relative and the total number of candidates registered under me in VTU and other Universities for both Ph.D.
& M.Sc. (Engg.) by Research taken

together excluding presently applied candidates is (in Words) The information provided above

is true to the best of my knowledge.

Date:
Place:
Signature : _________________________________________
Forwarded by ,...

Information of the Co-Supervisor( if applicable)

Name: .Date of Birth...

Affiliation: . .. Department:
DesignationArea of Research
Academic Qualification:
Programme
Degree
obtained
UG

University

Regular
/Distance

Specialization

% Marks obtained
with Class

Year of
passing

PG
Ph.D.
Others if any
No. of Publications in the preceding 5 years:
Research papers: 1. National Journal

communicated: 1. National Journal

2. International Journal
Conference:

1.

Technical Reports:

2. International Journal
Book:

Patents:

Awards:

No. of students Supervising:

Sl.
No.

Programme
Please tick (
)

Name of the
Candidate/s

Ph.D.

University

Category

Whether
Specify
Final
Year of
whether
Area of
Thesis
registration
acting as
Specialization
Submitted
Supervisor or
(Y/N)
Co Supervisor

M.Sc.
(Engg)

1
2
3
4
5
6
7
8
Total

Undertaking from the Co-Supervisor

I, is a permanent faculty /employee working as . in
the Department of . in the organisation .......and
is

aged

less

than

62

years

as

on

the

date

of

admission

notification

hereby

certify

Mr./Mrs....registering for ..... degree under

that

the

candidate

VTU is not

my

son/daughter/immediate blood relative and the total number of candidates registered under me in VTU and other Universities for both Ph.D.
& M.Sc. (Engg.) by Research taken

together excluding presently applied candidates is (in Words). The information provided above

is true to the best of my knowledge.

Date:
Place:
Signature : _________________________________________
Forwarded by ,...

Undertaking by Supervisor / Co-Supervisor *(in case Co-Supervisor is opted)

I / We have no objection in guiding the said candidate in the proposed area of research at the designated Research Centre.
If for any reason, myself /candidate change the Research Centre, I /we will inform the same to the University without
fail.
Signature of Co-Supervisor

Signature of the Supervisor

Signature of the Head of the Institution where the research work is proposed:.

No Objection Certificate of the Organisation

This is to certify that the

Organisation

has

no objection in recommending the candidature of

our

employeefor carrying out research for his/her Ph.D./ M.Sc. (Engg.) by research
at .... on part
time / full time basis. The information provided by the candidate is found correct as per our records.

Signature of the Principal/Head with Seal.

Employment Certificate of the Supervisor

This is to certify that Dr. presently working in the capacity

ofin the Department of... is a full time employee of
our Organisation, since..

Organisation:

Seal and Signature of the

Head of the Organisation

Employment Certificate of the Co-Supervisor (in case Co-Supervisor is opted)

This is to certify that Dr presently working in the capacity
ofin the Department of... is a full time employee of
our Organisation, since..

Organisation: ..

Seal and Signature of the

Head of the Organisation

* In case the candidate is applying under VTU-RRC, then a co-supervisor from VTU System is mandatorily to be opted.

Applicants Address for correspondence

.

.
Phone No.. email_id: ..
Supervisors Address for correspondence
.
.
Phone No.. email_id: ..
Co-Supervisors Address for correspondence
.
.
Phone No.. email_id:

Ph.D./M.Sc.(Engg)

Name of the Applicant:

Name of the Supervisor : .....
Name of the Co-Supervisor:.
Research Centre(VTU-RC/VTU-RRC):...
Programme:..
Mobile No: Phone ..
Enclose attested copies of the following, before sending the application :
1.

Detailed Bio-data of the Candidate, Supervisor (and CoSupervisor, if applicable)

2.

UG and PG degree Certificates and Marks cards of the

Candidate

Medical Certificate for the degree of disability in

support of candidates claiming benefit

3.

UG, PG and PhD

Supervisor/Co-supervisor

4.

Category certificate of candidates belonging to SC/ST/CatI/ and any other if applicable

Test Score Card along with Admission ticket in

support of clearance of UGC/UGC-CSIR
JRF/SLET/CAT/GATE/NET or any other National Test
with valid score

5.

Synopsis of the proposed research

6.

Syllabus of the Course work chosen for the present study

In case candidate/Supervisors are possessing

degree from Foreign Universities, The Equivalence
Certificate issued by the Association of Indian
Universities( AIU)

Passport with student Visa in the case of Foreign

candidates

7.

Degree

Certificates

of

the

Demand Draft of `.800 drawn in favour of The Finance

Officer, VTU, Belgaum towards Application and Processing
fee

9.

Any other additional Certificates supporting your claim

for benefits like:

VISVESVARAYA TECHNOLOGICAL UNIVERSITY

Application No.

Jnana sangama
Belgaum-590 018, Karnataka, India

APPLICATION FORM FOR UNIVERSITY LEVEL RESEARCH APTITUDE TEST (ULRAT)

Note:
1. This Form should be filled by all the candidates irrespective of their eligibility to be exempted from the ULRAT as
such an exemption is subject to a thorough scrutiny of supporting documents satisfactorily provided by the candidate
along with this Application

Test Centre Csode:

Bangalore

Belgaum

For those having

validity of VTU Tech.
Aptitude Test

None

Programme Stream Applied for:

1. Mechanical Engineering

7. Bio-Technology

13. Maths

2. Computer Science Engineering

8. Polymer Science

14. Physics.

3. Electrical Engineering

9. Silk Technology

15. Chemistry

4. Civil Engineering

10. Textile

16. Business Administration

5. Environmental Engineering

11. Chemical

17. Computer Applications

6 . Architecture.

12. Geology

1 17. Statistics

Educational Qualification which makes you eligible for the Programme

Program

Degree Awarded

Specialisation

Percentage of
Marks/CGPA with
Class

Specify Regular or Distance

Education

UG
PG
M Phil
Nationality: Indian
Category:

General

Gender: Male

Others (NRI/FN/PIO):
SC

ST

Whether Physically challenged

Cat-1
Yes

To be filled by candidates

OBC
No

Seat No.:

Female

Any Other.
: If Yes, Nature of disability:....

For Office Use only

Name:
Address.

Specify
the status of VTU TAT: Cleared in July 2010
Cleared in Jan 2011
Write the TAT Seat No.
.......................................
National
Test qualified with valid score
Date of ULRAT:
.
Programme
Are you
a facultyapplied
under for:
QIP/FIP:
Yes
No
Test Centre:
Address for correspondence:
Reporting Time:
..

Cleared

Paste ( do not pin )

passport
size
photograph in this
space and get it
attested by Principal
/ Head of College /
University
last
attended
or
a
in July 2011
Gazetted Officer

Candidates Signature

Whether any National Test Qualified:

Yes

No

If you possess VTU Technical Aptitude Test validity, then provide Seat No :...
Declaration by the Candidate

hereby acknowledge that all the information given

by me are true to the best of my knowledge. In the event of any information being found incorrect or
misleading, my candidature shall be liable to cancellation by the University at any time and I shall not be
entitled for refund of any fee paid by me to the University. I have carefully studied the Regulations(Amended)
Governing the Degree of Doctor of Philosophy (Ph.D.)-2011 framed under Section 32 of VTU Act 1994.

Date:

Signature of the Candidate

Visit www.vtu.ac.in for details regarding Regulations, Guidelines , Recognised Research Centres, Course
Work, Fee Structure and Syllabus for

ULRAT.