Application Form KHORANA PROGRAM FOR SCHOLARS 2012

1. Name: First name Surname 2. Male Female

Middle name

3. Date of Birth (dd/mm/yy): 4. Passport number: Country: Expiration Date: Date Issued: 5. Name of the University/Institution: 6. Address:

Institution / University Address Residential Address Landline Number # Telephone Alternative Telephone No. E-mail Skype id Mobile #

7. Major field of study: 8. Degree program currently enrolled in (e.g., BS, MS, B.Tech., MBBS, M.Tech., Integrated BS/MS): 9. Cumulative Grade Point Average / Percentage: 1

10. Expected date of Graduation (Completion of Degree): ____(mm) ____(yy) 11. Academic Record:
EDUCATIONAL QUALIFICATIONS (10th Standard onwards) Examination/ Degree University/ Board Institute/ College/ School Duration (from mm/yy to mm/yy) Subjects studied/ Specialization Percentage/ CGPA/ Rank

12. Please indicate if you are NOT comfortable working in a research lab that handles the following animals: ANIMAL Mice Worms Flies Cows Sheep Pigs Check here if you are NOT comfortable working with this animal

13. Statement of Purpose: Research interests, possible project ideas and what you hope to gain from this experience (Please restrict your response to the space given below)

14. Research experience, technical background, other internships, courses, lab work, techniques exposed to and past lab experience (Please restrict your response to the space given below)

15. References (One of the referees should be your teacher/tutor. In case you have completed a training/internship in any lab, a reference from your supervisor there would be preferred. The references should be provided on the official letter-heads of the Referees).
REFERENCES (Please furnish details of persons who can provide an assessment of your suitability for this internship) Details Name of Referee Organisation Designation Relationship with Applicant Email id Phone number # Reference 1 Reference 2

16. Signed and stamped no objection certificate from Parent InstitutionThis should be given on the official letter-head of the parent institution/organization in the following format: STATEMENT FROM PARENT INSTITUTION This is to certify that this institution has no objection to the consideration of application for Khorana Program for Scholars from Mr./Ms ..bonafide B.Tech./ M.Tech./ M.Sc. student in the (name of the department/institute/ organization) to undertake a research internship for the duration of 10 weeks at a U.S. university affiliated with the Khorana Program.

Place & date:

(Head of Institution/Organization)

17. Supporting Documentation check-list: Current transcript (Latest Marks sheet) Two letters of recommendation from a faculty member, advisor or lab supervisor on their official letterhead No objection certificate from Parent Institution (in the format provided in S.No. 16) 5

Photocopy of photo and information page of passport