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Affix latest passport size colour photograph

INDIAN INSTITUTE OF SCIENCE BANGALORE 560 012. APPLICA ION FORM

IISc. Summer Fellowship in Science and Engineering for SC/ST students - 2012 Name Permanent Address (with PIN code) Postal Address Telephone No. (with STD code) Mobile No. : E-mail ID Category (tick ( ) Physically handicapped (tick ( ) Course of study (tick ( ) Branch/Specialization of study Name & Address of the College (with PIN code) University State Educational qualifications:
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SC ] Yes [

[ [ ] ]

ST No

[ [

] ]

First year M Sc. during(2011-12)

Third Year BE/B.Tech during 2011-12 [ ]

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Course of study 1. 12th Std 2. B.Sc. 3. M.Sc or Equivalent 3. B.E/B.Tech I Year II Year

Discipline/branch

% marks obtained Rank/s, if any (excluding languages)

Preference of the Department for Project work (please refer www.iisc.ernet.in for list of Departments)

Educational Qualifications of parents : (Please tic whichever is applicable)

Father : Not studied / Primary / Middle School / High School / SSLC/ Graduate / Post-graduate Mother : Not studied / Primary / Middle School / High School / SSLC/ Graduate / Post-graduate

Annual income of Parents Rs Parents Domicile Urban Semi Urban

(In the event of selection proof to be produced)

Rural

Date

Signature of the Applicant

Note: Please don t enclose copies of certificates/marks cards with this application. Original certificates/ marks cards will be verified only after selection

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