ApplicationForm

S.N.BOSESCHOLARSPROGRAM2015
1. Name:
Firstname
Surname

Middlename

2. MaleFemale
3. DateofBirth(dd/mm/yy):
4. Passportnumber:
Country:
ExpirationDate:
DateIssued:
Ifyoudonothaveapassportandhaveappliedforit,mentionAppliedFor
5. NameoftheUniversity/Institution:
6. Address:
Institution /
University Address
Residential Address
Landline Number #

Mobile #

Telephone
Alternative
Telephone No.
E-mail
Skype id

7. Majorfieldofstudy:
8. Degreeprogramcurrentlyenrolledin(e.g.,BS,MS,B.Tech.,MBBS,M.Tech.,
IntegratedBS/MS):

9. CumulativeGradePointAverage/Percentage:
10. ExpecteddateofGraduation(CompletionofDegree):____(mm)____(yy)
11.AcademicRecord:
EDUCATIONAL QUALIFICATIONS (10th Standard onwards)
Examination/
Degree

University/
Board

Duration
(from
mm/yy to
mm/yy)

Institute/
College/
School

Subjects studied/
Specialization

Percentage/
CGPA/
Rank

12.StatementofPurpose:Researchinterests,possibleprojectideasandwhatyou
hopetogainfromthisexperience(Pleaserestrictyourresponsetothespacegiven
below)

13.Researchexperience,technicalbackground,otherinternships,courses,lab
work,techniquesexposedtoandpastlabexperience(Pleaserestrictyourresponse
tothespacegivenbelow)

14.References(Oneoftherefereesshouldbeyourteacher/tutor.Incaseyouhave
completedatraining/internshipinanylab,areferencefromyoursupervisorthere
wouldbepreferred.Thereferencesshouldbeprovidedontheofficialletterheadsof
theReferees).
REFERENCES
(Please furnish details of persons who can provide an assessment of your suitability for this internship)
Details

Reference 1

Reference 2

Name of Referee:

Designation:
Organisation:
Email id:
Phone number:
Relationship with Applicant

15.SignedandstampednoobjectioncertificatefromParentInstitutionThis
shouldbegivenontheofficialletterheadoftheparentinstitution/organizationin
thefollowingformat:
STATEMENTFROMPARENTINSTITUTION
ItiscertifiedthatMr./Ms..bonafideB.Tech./ M.Tech./M.Sc.
student is a first/ second rank holder of the (name of the
department/institute/ organization), and the institution endorses him/her for the S. N.
BoseScholarsProgram.
This is to also certify that this institution has no objection to the consideration of
application for S.N. Bose Scholars Program from the above student to undertake a
researchinternshipforthedurationof10weeksataU.S.universityaffiliatedwiththe
S.N.BoseScholarsProgram.
Place&date:(HeadofInstitution/Organization)

16.SupportingDocumentationchecklist:
Currenttranscript(LatestMarkssheet)
Twolettersofrecommendationfroma
facultymember,advisororlabsupervisorontheirofficialletterhead
NoobjectioncertificatefromParentInstitution
(intheformatprovidedinS.No.16)
5

Scannedcopyoffirstandlastpageofpassport