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Application Form

KHORANA PROGRAM FOR SCHOLARS 2012

1. Name:First name Middle name

Surname

2. Male Female

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

Telephone

Landline Number # Mobile #

Alternative

Telephone No.

E-mail

Skype id

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:

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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

Percent-

age/

CGPA/

Rank

12. Please indicate if you are NOT comfortable working in a research lab that

handles the following animals:

ANIMAL Check here if you are NOT comfortable

working with this animal

Mice

Worms

Flies

Cows

Sheep

Pigs

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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)

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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)

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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 Reference 1 Reference 2

Name of Referee

Organisation

Designation

Relationship with Applicant

Email id

Phone number #

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)

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Photocopy of photo and information page of passport

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