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INDIAN INSTITUTE OF SCIENCE BANGALORE 560 012. APPLICATION 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 SC ] Yes [ [ [ ] ] ST No [ [ ] ]

First year M Sc. during(2011-12)

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

Educational qualifications:

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

1 Electrical communication engineering department 2 Electrical department 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(In the event of selection proof to be produced) Parents Domicile Urban Semi Urban Rural

Date : Applicant

Signature of the

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