RAJIV GANDHI INSTITUTE OF PETROLEUM TECHNOLOGY, JAIS, AMETHI

(An Institute of National Importance Established under the Act of Parliament)

Application Form for Admission to Doctoral Programme

(Note: Candidates applying for more than one discipline should submit a separate application for each discipline )
Disciplines: (A) Petroleum Engineering & Geological Science: Petroleum, Geology and Geophysics.
(B) Engineering Sciences: Chemical, Material Science, Electrical, Civil and Geo-informatics.
(C) Basic Sciences & Humanities: Physics, Chemistry, Mathematics, Statistics, Biological
Science, Material Science, Renewable Energy, English and Sociology.
(D) Management : Accounting & Finance, Marketing, Organization Behavior & Human
Resource Management, Operations Research, Oil and Gas, Public Policy, Energy
Management.

Discipline & Ph.D. Program Apply in:

Affix your recent
Photograph not
Category: (Regular/Sponsored/Part-Time) more than three
Month

1. Name of Applicants: (as in qualifying degree certificate)

Name

2. Name of Father/Mother: (as in qualifying degree certificate)

Name

3. Contact details:

Address for communication: Permanent Address:

Pin Pin
City: Code City: Code
State: State:
Mobile Number Alternate Mobile Email Address: Marital status:
Number:

Date of Birth: Nationality: Gender: Category: GN/OBC/SC/ST/PH

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 4. GATE/UGC-NET/CSIR-UGC/CAT/GMAT/GRE Etc. performance:

GATE/UGC- GATE/UGC- GATE/UGC- GATE/UGC-

NET/CSIR- NET/CSIR- NET/CSIR- NET/CSIR- No. of
Name of Marks Out All India
UGC/CAT/ UGC/CAT/ UGC/CAT/ UGC/CAT/ Students
Examination of 100 Rank
GMAT/GRE GMAT/GRE GMAT/GRE GMAT/GRE Appeared
Etc. Year Etc. Score Registration No. Subject/Paper

Do mention the GATE marks/100, qualifying marks, All India Rank etc., if applicable for you)

5. Details of academic record in chronological order: (Attach as separate Annexure in the

following format)
School/College
Year of Year of CPI/% age Class/
Degree Subject /University/
Joining Leaving of marks Division
Institution

6. Specify the likely date of master's degree completion (if not completed)

7. Break of study, if any specify no of years:

8. Papers published/accepted in Journals: (Enclose reprints of best (according to your own
assessment) five papers published in Journals) (Attach as a separate annexure in the
following format, if necessary)
Sl. Author (s) Title of the Name of Vol. Page No. Year Impact No. of
No. paper Journal No. From to factor Citations

9. M. Tech/M.Sc. Thesis Abstract/ Research Proposal: (in 50 words) (Attach as a separate sheet, if
necessary)

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10. Details of any past experience: (Attach as a separate Annexure in the following format, if necessary)
Total Period of employment
Position Present PB & GP & Experience Nature of
Organization
Held Basic Pay (In Rs.) (in year & Duty
From To
Month)

11. Applied any time earlier to RGIPT for any Position/Job/Admission: …………………………………
12. Any Gap between the studies: ……………………………………………………………………………………………
13. Any other Academic Achievements/Awards/Contribution: ……………………………………………...
14. Proposed Date & Time (you would be available for written test and/or presentation, interview)…………….....
Declaration:
I hereby declare that the information given above is correct to the best of my knowledge and
belief. I am also aware that providing incorrect information in the application form can result in
the cancellation of my admission at any stage.

Place:
Date: Signature of the Applicant

Please send the completed application form to the following address with “Application for PhD
Admission in the discipline………….” written on envelop.
Academic Office
Administration Building
Rajiv Gandhi Institute of Petroleum Technology
Mubarakpur, Mukhtia,
Post: Harbanshganj
Jais, District: Amethi-229304
Email: admission@rgipt.ac.in

Check List for Enclosures: (Please √)

 Color photo fixed on the application form.
 Self-attested copy of GATE/CSIR/UGC/NBHM/DBT/GPAT Score Card (if applicable).
 Self-Attested copy of X Class Mark sheet & Certificate.
 Self-Attested copy of XII Class Mark sheet & Certificate.
 Self-Attested copy of UG Grade sheets/Final Grade Report & Degree Certificate.
 Self-Attested copy of PG Grade sheets/Final Grade Report & Degree Certificate.
 Self-Attested copy of work experience certificate.
 Self-Attested copy of Category Certificate (if applicable).
 Self-Declaration Form by OBC Non Creamy Layer (if applicable).
 Physically handicapped Certificate (if applicable).
 “Sponsorship Certificate” & “Employer Consent” by sponsored candidate (if applicable).
 “No Objection Certificate” & “Employer Consent” by Part Time candidate (if applicable).
 Three Years Leave approval by employing agency by sponsored candidate (if applicable).
 One Year Leave approval by employing agency by Part Time candidate (if applicable).
 Self-Attested copy of copies of publications (if applicable).
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