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17 views

Annexes9

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whitewolfforlol
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Annexure- IX

APPLICATION FORMAT FOR ICMR JUNIOR RESEARCH FELLOWSHIP


PROGRAMME (FOR ICMR- JUNIOR RESEARCH FELLOW)

INDIAN COUNCIL OF MEDICAL RESEARCH

V.RAMALINGASWAMI BHAWAN ANSARI NAGAR,


W.POST BOX 4911, NEW DELHI-110029

NB: a) The application should be typed (except item 5, which should be filled by hand).
b) All answers should be given in words and not be dashes.
c) Strike off those statements, which are not applicable.
d) The application in duplicate is to be sent to Director General, (Attention: Head,
HRD), Indian Council of Medical Research, V. Ramalingaswami Bhawan, Post Box
No. 4911, New Delhi -110029

1. GENERAL INFORMATION
Name (in Block Letters) : _________________________________
Underline surname

Year of passing : _________________________________

Roll No. : _________________________________

Postal address for correspondence : _________________________________

_________________________________

_________________________________

Email address : _________________________________

Phone number : _________________________________

Permanent address : _________________________________

_________________________________

_________________________________

Date of Birth : _________________________________

Duration of fellowship desired : _________________________________

State whether you are at present in : _________________________________


receipt of any stipend or fellowship
from your Institute, or from any _________________________________
other source. If so, state the nature
of the fellowship amount and the _________________________________
source of receipt

Particulars of other fellowships, : _________________________________


if any, applied for with dates
and names of agencies _________________________________

Particulars of ICMR fellowships, : _________________________________


if any, applied/availed in the past
(Quote ICMR Ref. No.) _________________________________

List of fellowships in India and : _________________________________


abroad so far availed, indicate
name of Agency, university, with _________________________________
date. A brief account of work
done on each fellowship may be
enclosed in a separate sheet

Give names and address of two : _________________________________


references other than the Guide

2. ACADEMIC RECORD:

List serially the particulars of all examinations passed from Matriculation/Higher


Secondary onwards and enclose attested copies of certificates/degrees for each of
the examinations passed and mark sheets for Graduate and Post Graduate
University examinations passed. Explain gaps in study, if any, by indicating number
of failures, attempt

Examination Year of Name of Class / Aggregate Distinction Failure / Subject


study school/ Division Marks In subjects Attempts of thesis,
From to college / obtained Subjects If any
Univ And
numbers
Matric
Higher
Secondary
Pre-
Professional

B.Sc.

M.Sc.
(State the
subject)
Any other
Examination
passed
Note: State Medals, Scholarships, price and any other award, distinction or honour
won during your University career.
3. PARTICULARS OF RESEARCH ON WHICH THE CANDIDATE DESIRES TO
WORK:

1. Title of project ____________________________________________________

(a) Specialty covered by the Research work ___________________________

(b) Nature of work-Clinical/Experimental Combined/Field Project (Strike off what is


Irrelevant) _________________________________________________________

(c) State whether any travelling is involved in the programme of work. if so, state
how the travel expenses will be met as no separate funds for travel are provided to
the fellow

(d) Name and designation of the Guide under whom the candidate will work

(e) Name of Institution & University

(t) If fellowship is desired for any Degree work, indicate:


(i) Degree for which registered! wish to register ________________________
(ii) Title of project for thesis ________________________________________
(iii) Date of Registration ___________________________________________
(iv) Date of Examination ___________________________________________

Attach separately two copies of detailed plan of proposed work under the following
headings:
1. Title of the Project .
2. Name, designation and address of the Guide
3. Tenure of the study
4. Objectives
5. Present knowledge and relevant bibliography (please give here only the most
relevant references complete with the authors name(s), title of the article,
name of the Journal, year. volume and page number).
6. Methodology and Techniques (giving all relevant details like study design,
selection of subjects experimental model, techniques study proforma etc.).
7. What is aimed to be achieved by the study?
8. How is it likely to advance or add to the existing knowledge in relation to
human health?

4. DECLARATION BY THE CANDIDATE


1. I have gone through the Fellowship Rules and conditions of the award and if
selected, I agree to abide by them. The particulars given in the form are
correct and I am prepared to present myself for interview at my own
expenses, if called upon to do so.
2. Certified that in the event of my being offered the Council's fellowship, I am
prepared to give up my present stipend/fellowship salary/but not the leave
salary.

3. Certified that I will be able to manage within the contingent grant allotted for
the fellowship. I also certify that no non-expendable articles or equipment will
be purchased by me.

Signature of the applicant


5. TO BE FILLED BY THE RESEARCH GUIDE IN HIS OWN HANDWRITING:
1. Major field of your specialization.
2. What are your current area(s) or Research?
3. The number and names of Research students including fellowships awarded
by R&D Agencies (like ICMR, CSIR, DAE, ICAR DGHS, UGC, SMRC,
Pharmaceutical companies etc.) currently being guided:
4. Titles of the research schemes including sponsored ones in hand:
5. Your opinion on the research potentiality of the candidate and relevance of
the project
to your field of interest:
6. I agree to accept the applicant ____________________ and offer him/her all
facilities and guidance for carrying out research/training in the ___________
Project _____________________ of ________________ proposed by the
applicant which has been drawn in consultation with me and has my approval.
I also certify that the applicant will not receive any financial assistance from
my side, for carrying out the work in my department.
7. Certified that the proposed project has not been submitted earlier in any
shape.
8. Certified that the techniques to be employed in carrying out the work of the
research project have been standardised.
9. Certified that the plan of work has been prepared in consultation with a
Statistician (Strike out if not considered necessary).

Signature of the Guide


Seal bearing designation &
Address

6. CERTIFICATE BY THE HEAD OF THE INSTITUTE:

i. I recommend _______________________________________for the fellowship


applied for and certify that, to the best of my knowledge he/she is eligible for it
in all respects.
ii. I certify that he/she will/will not receiving any stipend pay/allowance and
financial assistance except leave salary from any source in case ICMR JRF is
awarded.
iii. I certify that the research proposal has been reviewed and recommended by
the institute's academic committee.
iv. I certify that all the equipment, laboratory and other facilities required for
carrying out
the proposed research project by the applicant are available in the
Department/Institute and will be made available to the applicant.
v. I undertake to send to the Council an audited statement of accounts along with
the utilisation certificates as required in the Fellowship Rules.

Signature of the Head of the Institution


(Seal bearing Designation & Address)
7. BIO-DATA OF THE GUIDE/CO-GUIDE*

Name : Dr. Miss/Smt/Shri* _____________ __________________

Designation :
Address :
Phone number :
Email :
Date of birth :

First Name(s) :

Last Name :

Educational Qualification: Degrees obtained (Begin with Bachelor's Degree)

Degree Institution Field Year

1.
2.
3.
4.
5.

Research/Training Experience:

Duration Institution Particulars of work done

1.
2.
3.
4.

Research specialization:
1.
2.
3.
4.
__________________________________________________________________
* Strike out which is not applicable

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