2 4 1 9 7 1 3 9 8

Date of Registration/Print: 25-08-2023/26-08-2023 Reference No: 241971398

Application for Ph.D. Programme - January 2024 Session

1. Degree : Ph.D. Industry

2. Name : Mr. M R
3. Date of Birth : 01.01.1990
4. Gender : Male
5. Marital Status : Married
6. Community : BC
7. E mail : [email protected]
8. Mobile : 1234567890
9. Aadhar No. : 12345678902
10. Nationality : Indian
11. Category : Part - Time
Working in Industry/Government/Private
Organisation

12. Faculty : Science and Humanities

13. UG Specialisation : B.E.-Civil Engineering
14. PG Specialisation : M.E.-Structural Engineering
Degree Awarded : Yes
15. Exam Subject Code : PCE1001
16. Contact Details

Office Address Residential Address

MR MR
Senior Professor MHM
Cfr V
AU CHENNAI
Chennai TAMILNADU
CHENNAI 600025
TAMILNADU
600025

17. Supervisor Details:

Supervisor Reference No. : 123456 - xxxxx x
Supervisor Recognised department : 1100100 / College of Engineering Campus, Chennai / All
Departments and Centres
18. Joint Supervisor Details : Not Applicable

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Date of Registration/Print:25-08-2023/26-08-2023 Reference No. : 241971398

19. Father Name : R

20. Mother Name : S
21. Spouse Name : R
22. Differently-abled : no
23. Academic Background (Starting from the latest degree obtained)
Sl. Qualificat Branch Mo College & University Univer Durati Year of % of M Certificate
No. ion de sity on(in Passing arks/C No.
Type Year) GPA
1. M.E. Structural FT Anna University State U 2023 68.00 235
Engineering niversit
y
2 B.E. Civil Engineering FT MKU State U 2019 70.00 123
niversit
y
3 HSC PCM FT TN 2016 70.00 341
4 10th Maths FT TN 2014 70.00 456

24. Professional Experience (Starting from the Present Employment)

Sl. Designation College / Organisation From To Regular/ Type Total
No. Temporary/ Years
Contract
1.
2.
3.
4.
5.
Total 0
25. Publication Details
Sl. Name of the Paper Title Author Year of Paper URL
No. Journal Publication
1.
2.
3.

26. Organization Details : (For Industrial Candidates)

Organization Type : Public Sector Undertaking
Year of Started : 1995
Yearly Turnover : 5 Crore
No. of Employeee : 150
Distance from Supervisor : 48 KM
Place

27. Proposed Research Topic : sdff

Major Domain : dd

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Date of Registration/Print:25-08-2023/26-08-2023 Reference No. : 241971398

SUPERVISOR DETAILS
Name / Reference No. Dr. xxxxx x / 123456
Designation Assistant Professor
Nature of Appointment Regular
Department xxxxx
College/Organization Address CEG, Chennai, Chennai , - 600025
Mobile No. 1234567890
Date of Retirement 30.06.2034
Area of Specialization Cloud Computing
AU Recognised research 1100100 / College of Engineering Campus, Chennai / All Departments
department/centre/institute of Supervisor and Centres

Details of scholars doing research under his/her guidance as Supervisor/Joint Supervisor

Sl. No. Name of the Scholar Reg. No. Degree Faculty Year/Session Supervisor Research
/ Joint Sup. Status

(Research Status – Course work / Registration Confirmed / Synopsis Submitted / Thesis Submitted)
Certified that I have listed all the research scholars registered under my guidance as Supervisor / Joint Supervisor.

Signature of Supervisor Signature of HOD/Director of the Centre of the Supervisor

(Name with Seal) (Name with Seal)

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Date of Registration/Print:25-08-2023/26-08-2023 Reference No. : 241971398

b) Joint Supervisor : Not Applicable

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Date of Registration/Print:25-08-2023/26-08-2023 Reference No. : 241971398

1. Online Fee receipt

2. One page write up of Research topic signed by the Candidate, Supervisor and
Joint Supervisor ( if any )
3. Self attested photocopy of Community Certificate (except for Forward community)
4. Self attested photocopy of 10th or its equivalents
5. Self attested photocopy of HSC or its equivalents
6. Self attested photocopy of UG consolidated mark sheet
7. Self attested photocopy of UG Degree Certificate
8. Self attested photocopy of PG Consolidated Mark Sheet
9. Self attested photocopy of PG Degree Certificate
10 Self attested photocopy of the last Transfer Certificate
11. Self attested photocopy of the appointment order (if Part-time)
12. Project sanction order to the Principal Investigator (if applicable)
13. Relieving order from the employer (Employed candidates, who want to pursue full-time study)
14. No Objection Certificate (if applicable)
15. Experience Certificates (if applicable)
16. Industry Details (if applicable)
17. Residential Proof for industrial Candidate(if applicable)

Declaration

I hereby certify that the particulars given above are true, correct and complete to the best of my knowledge and
belief. I am aware that any wrong information or suppression of information and facts may result in punitive action in
addition to cancellation of Ph.D. programme at any stage.
For Industry Candidate
Distance from Supervisor Organisation to the organisation where the Candidates is employed is 48 Km.

Place :
Date : (Signature of the Candidate)

Signature of Supervisor Signature of HOD/Director of the Centre of the Supervisor

(Name with Seal) (Name with Seal)

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No objection certificate from Engineering College/Research Organization/Industry

Where the Candidate is Employed

Certified that Mr./Ms./Mrs. ______________________ is employed as (Designation)

__________________________ in the (Department / Division) __________________________ of (Engineering
College / Organization / Industry) ______________________________________________. The College /
Organization / Industry has no objection to forward his / her application for admission to Ph. D. Programme.

FOR FULL-TIME:
The employee will be sanctioned study leave for the minimum duration of the research programme and will be
relieved from duty from _______ to _______ in order to undertake Full-time research work in the University
Departments/recognized Departments of Engineering Colleges. The necessary relieving order will be given during
admission.

(OR)

FOR PART-TIME:
The employee will be permitted to undertake Part-time research in the University Departments/recognized
departments of Engineering Colleges and he/she will be permitted to be present for attending course works,
discussion with the supervisor, conduct experiments and participate in seminars and research related discussion.
Further, the required facilities at our Institute/ organization/ Industry will also be provided to the employee for doing
research.

(Strike out whichever not applicable)

Place :
Date : Signature of the Principal with office seal / Signature of the
Head of the R&D organization with office seal

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Date of Registration/Print:25-08-2023/26-08-2023 Reference No. : 241971398

List of Proposed DC Members for Ph.D. Programme

Name of the Candidate : MR

Research Topic : sdff
Supervisor : Dr. xxxxx x,xxxxx,CEG,Chennai
Joint Supervisor : Not Applicable

Members from Anna University and Affiliated Colleges

Sl. No. Name with Address Area of Specialization
1. Name : Dr. Rejinpaul N.R. xx
Designation : Professor
Department : s
Organization/Institution : xx,x-123456
& Addr.
Mobile :
E-Mail :

2. Name : Dr. x xx
Designation : Professor
Department : s
Organization/Institution : xx,y-123457
& Addr.
Mobile :
E-Mail :

3. Name : Dr. x xx
Designation : Professor
Department : s
Organization/Institution : xx,Z-123457
& Addr.
Mobile :
E-Mail :

Signature of Supervisor Signature of Joint Supervisor Signature of HOD/Director of the Centre of

(Name with Seal) (Name with Seal) the Supervisor
(Name with Seal)

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Members from other University / Institutions (preferably within Tamil Nadu)

Sl. No. Name with Address Area of Specialization

1. Name : Dr. x x
Designation : Professor
Department : s
University/Institute & : cc,B-123456
Addr.
Mobile :
E-Mail :

2. Name : Dr. x xx
Designation : Professor
Department : s
University/Institute & : bb,F-123456
Addr.
Mobile :
E-Mail :

3. Name : Dr. x xx
Designation : Senior Professor
Department : s
University/Institute & : cc,K-123456
Addr.
Mobile :
E-Mail :

Signature of Supervisor Signature of Joint Supervisor Signature of HOD/Director of the

(Name with Seal) (Name with Seal) Centre of the Supervisor
(Name with Seal)

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 Date of Registration/Print:25-08-2023/26-08-2023 Reference No. : 241971398

FEE RECEIPT
( Office Copy )

Application for Ph.D. Programme January 2024

Reference Number : 241971398

Name of the Candidate : MR

Degree : Ph.D.

Faculty : Science and Humanities

FEE DETAILS FEE STATUS

Application Fee : 1000 Payment Successful

GST(18%) : 180

Total : 1180

Paid Date : 2023-08-26 10:15:30

Mode of Payment : Net Banking

Transaction Id : 18010342735

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