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INSTITUTE OF CHEMICAL TECHNOLOGY(University Under Section -3 of UGC Act 1956)

N. M. Parekh Marg, Matunga, Mumbai 400 019 INDIA

Tel: 91-22-3361-1111/ 2222 Fax: 91223361-1020,

Email: admission@ictmumbai.edu.in; admission.ict@gmail.com

Website : www.ictmumbai.edu.in

APPLICATION FORM FOR ADMISSION TO

Ph.D. (Tech.) / Ph.D. (Sci.)

Integrated Ph.D. (Tech.) (after B.Chem.Eng./B.Tech.)

Branch: _________________________ Dept.: ______________________

1. (a) Applicants name as per the format of Government of Maharashtra (In Block Letters)

____________________ _________________ _______________________ _________________

Surname/Family Name First Name Fathers/Husbands Name Mothers name

(b) NameAppearingonsupportingdocumentsasSchool/Board/Jr.College/UniversityCerticates

____________________________________________________________________________________

2. DATE OF BIRTH: _____ _____ _____ Place of Birth _________________ State __________________

(dd) (mm) (yyyy)

3. (a) SEX : MALE FEMALE (b) MARITAL STATUS : Married Single

4. NATIONALITY _____________________________ DOMICILE STATE __________________________

5. ADDRESS FOR CORRESPONDENCE (In Block Letters):

________________________________________________________________________________________

________________________________________________________________________________________

Village/Town/City:- _________________ Taluka:- _________________District:- ______________________

State ___________________ PIN _____________________ Mobile No ____________________________

STD Code: ____________________________ Phone No (land line): _______________________________

6. PARENTS / GUARDIANS NAME & ADDRESS:

________________________________________________________________________________________

________________________________________________________________________________________

Village / City:- _________________ Taluka:- ___________________ District:- _______________________

State ___________________ PIN _____________________ Mobile No ____________________________

STD Code: ____________________________ Phone No (land line): _______________________________

7. (a) Applicants E-Mail address: _____________________________________________________________

(b) E-Mail address of Parent / Guardian: ______________________________________________________

8. Religion : _______________________________________________________________________________

9. Category(Pleaseinappropriatebox)

Open SC STFROM MAHARASHTRA STATE ONLY

VJDT/NT-A NT-B NT-C NT-D OBC SBC

10. Details of the Qualifying Examination: (Give Details)

______________________ _____________ _________________ _______________

Month and Year of Passing Seat No. Marks % / CGPA Class

College/Institution : ____________________________________________________________________

University : ____________________________________________________________________

Subject / Courses Studied : ____________________________________________________________________

GATE / GPAT / NET / SET / Other : _________________ _________________________ ___________

Seat No. Month and Year of Passing. Score

11. Proposed Area of Research and Name of Proposed Faculty Member of ICT as Research Supervisor

1. ______________________________________________

2. ______________________________________________

3. ______________________________________________

Application No. Handbook No.________________

INSTITUTTE OF CHEMICAL TECHNOLOGY, (University under Section 3 of UGC Act 1956), MATUNGA, MUMBAI- 400 019.

Received an application for admission to Ph.D. (Tech.) / Integrated Ph.D. (Tech.) / Ph.D.(Sci.) Degree course from

Shri/Smt. ________________________________________________

Date __________________________ ____________________________________

(Receivers Signature with Stamp)

NB : Please enclose a self addressed envelope (22 X 10 cm.) bearing Rs.5/- postal stamp for receiving the acknowledgement by post.

Afx your

recent

coloured Photograph

Size - 45 x 35 mm

FOR OFFICE USE ONLY

(Applicant shall not write

Anything in this space)

Whether admitted

YES

NO

Provisional

Conrmed

Fellowship available

YES

NO

Name of fellowship

_____________________

_____________________

Receiving Date

_____________________

Receivers Signature

_____________________

Signature of Head of

the Department

Application No :

Handbook No:

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12. Family Data: - (Only Parents, Brothers & Sisters)

No. Name of Family Member Date of BirthEducational

qualicationCurrent Occupation

Approx. Annual

Income, `

1

2

3

4

5

13. ACADEMIC RECORD:

Examination Board / University Month &

Year of

Passing

Total

Marks

Obtained

Maximum

Marks

%

Marks

Class /

CGPA

Name of College / Institute

SSC / Std. X or Equivalent

HSSC/Std. XII or Equivalent

B.Sc./B.E./B.Chem.Engg./

B.Tech. / B.Pharm. /

Equivalent

M.Sc./M.E./M.Chem.Engg./M.Tech./M.Pharm. Part - I

Part - II or Thesis

GATE / GPAT /SET / NET / other (Attach attested copies of all the Statement of Marks)

14.Accountforacademicbreak,ifany/(Pleaseattachafdavitforthesame)_________________________________________________

15. Academic /Industrial Experience, (if any) (Mention position held, period and Organization / Institute)

16. Documents to be attached: - Please Refer Handbook

DECLARATION IhavereadtheinstructionsgivenintheHandbookcarefullybeforellingupthisform.Theinformationgivenaboveistrue,completeandcorrect to the best of my knowledge and belief. In the event of any information being found false or incorrect, my admission may be cancelled

without any notice. If admitted, I shall abide by all the rules, regulations and discipline of the Institute. I shall not involve myself in any ragging

or anti-social activities which will not only tarnish my own but also the institutes image and if I come to know any such incidence, I shall report

it to the authorities. I will also submit the undertaking regarding the anti-ragging measures, once admitted.

Place ________________________

Date ________________________ __________________________________

Signature of Applicant

FOR OFFICE USE ONLY :

1. Research Supervisors Comments 3. Financial support to the Candidate

New student / Already guided Fellowship agency _______________________

Guidance Available / not available With / Without HRA ______________________

Research Scheme ________________________

Remarks _______________________________

Signature of Guide with Date _______________

2. Current enrolment of research students

withtheguideexcludingthisapplicantis 4. Remarksbyofce:

Masters : ________ May be Admitted / May Not be Admitted, Date __________

Doctoral : ________ Fees Receipt No.______________ Date ________________

Approved / Not approved

____________________ Signature of Dean

AR (Academic) (Academic Programme)

Please read very carefully all instructions given in the Handbook before

llingupthisformandsubmitthecompletedformbeforethelastdate.Anymisrepresentationofrecordsorover-writingonofcialdocumentswillleadrejection of the application form.