LTV

BIRLA INSTITUTE OF TECHNOLOGY & SCIENCE WORK INTEGRATED LEARNING PROGRAMMES DIVISION PILANI 333 031 RAJASTHAN Application for Admission to four-semester M.S. Embedded Systems in collaboration with L & T IES Vadodara

For Office use only

Date of Receipt: ________________________

ID No. Remarks, if any: _____________________________________________________________________________ Dean Vice-Chancellor

Note: Please read the instructions given at the end carefully before filling in this application form.
SECTION 1: PERSONAL INFORMATION & EDUCATIONAL BACKGROUND 1. Full Name: (in Capital Letters as it appears in degree/ diploma certificate) 0 2. 2.1 Date of Birth 5 0 3 1 9 8 1 P R A S A D A H A R I S H G H O L E

Affix Unattested Passport Size Colour Photograph

Date 3 0 Years

Month 1 2.2 1 Months Age

Year

M 3. 4. Sex: (Enter 'M' if Male & 'F' if Female) N Do you belong to Scheduled caste or Scheduled tribe? [Y/N] I 1 of 6

5. 6.

Nationality ('I' if Indian, 'O' if any other) If 'O' to above, specify (a) Father's Name: HARISH KRISHNA GHOLE (b) Mother's Name: HARSHADA HARISH GHOLE

7. 8. 9.

Marital Status (fill in 'M' if Married, 'S' if Single) Do you have access to Internet ? [Y/N] Email address: prasad.ghole@gmail.com

M Y

(Please be careful about capital / small letters, underscore, hyphen, space etc.. Candidates without access to e-mail / internet access facility will not be considered for the programme.)

10. Can you be contacted by telephone? At Office: (Y/N) At Residence: (Y/N) Mobile Phone: (Y/N) 11. Do you have FAX? (Y/N) N N Y STD Code: STD Code: 022 Number : STD Code: 9987005130 Number: LTV ________________________ Number: Number: 27465130

12. Mailing Address (in Capital Letters) to which all postal correspondence is to be sent: Line 1 of address: 103, SUNRISE , NEPTUNE LIVING POINT, METRO MALL, Line 2 of address: NEAR MANGATRAM PETROL PUMP, BHANDUP (W) City MUMBAI State MAHARASHTRA

Pin / Zip Code 400078 13. Permanent Home Address (in Capital Letters):

Country INDIA

Line 1 of address: 1, HARI MAMTA C.H.S., SECTOR 10, NEW PANVEL (E) Line 2 of address: ____________________________________________________________________________ City NEW PANVEL State MAHARASHTRA

Pin / Zip Code 410206 14.

Country INDIA

Educational details from School Leaving Certificate onwards in chronological order:

Subjects / Branch SSC Duration of Diploma / Degree 1 Board / University MAHARAS HTRA MAHARAS HTRA Year of passing 1996 Total Marks Obtained 471 Maximum Marks 750 Final %age of Marks* 62.80 Div. FIR ST FIR ST

Name of Diploma /Degree Class X or equivalent (specify) Class XII or equivalent (specify) Technical Diploma / BSc or equivalent (specify)

HSC

1998

437

600

72.83

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BITS BS / BE / MSc / MBA / MCA / AMIE or equivalent (specify) Any other (specify)

ELECTRON ICS

MUMBAI

2002

1715

3000

57.23

SEC ON D

* As calculated for declaring result and award of Division by your Board / University. If marks are not awarded give Cumulative Grade Point Average or its equivalent. Explain the basis on which your B.E. / M.Sc. / M.C.A. (or equivalent) final percentage is calculated BE Marks are calculated on basic of last 4 semesters average. _______________________________________________________________________________________________________

Clearly explain gaps, if any in a separate sheet. 15. 16. Indicate the Level at which you have studied Mathematics. Upto class XII Level fill 1, upto Technical diploma / B.Sc. or equivalent Level fill 2, upto B.E. / M.Sc. or equivalent Level fill 3. Are you currently enrolled for degree or diploma in any University / Institution: (Y/N) 3 N

If Yes give details specifying the University / Institution name, programme name, duration, date of joining the programme and likely date of completion of the same. ___________________________________________________________________________________________ 17. Have you ever been a student of BITS, Pilani. (Yes / No): if yes, please write name of the degree and your ID No. ___________________________________________________________________________________________

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LTV ________________________
18. Total Work Experience: Years 7 Months 1 (as on application deadline to be counted only from the point of completing BE / MSc or equivalent) 0 3 0 2 19. Work Experience in Current Organization: Years Months (as on application deadline to be counted only from the point of completing BE / MSc or equivalent) 20. Employment Details: Since the year of completing BE / MSc or equivalent, give brief employment details below in reverse chronological order. Name of the Employer L&T IES PANORAMA INFOCOM PVT. LTD. SOFTDEL SYSTEMS PVT. LTD. MAESTROS MEDILINE SYSTEMS LTD. INTEGRATED AUTOMATION SYSTEMS (I) PVT. LTD. Designation held SENIOR SOFTWARE ENGINEER TEAM LEAD SOFTWARE ENGINEER R & D EXECUTIVE ELECTRONIC ENGINEER Period* of Employment 9/11/2009 TILL DATE 6/5/2009 7/11/2009 22/01/2007 03/05/2009 30/05/2005 18/01/2007 01/01/2005 27/05/2005 Years 2 0 2 1 0 Months 3 6 3 7 4 Days 12 1 12 18 26

Total Work Experience calculated after completing BE / MSc or equivalent

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* Provide the dates of start and end of the employment period. Clearly explain gaps, if any in a separate sheet. 21 Declaration by the Applicant I have carefully read the programme details and the instructions given in this application form and hereby declare that all the information given and statements made in various sections and parts of this Application Form and enclosures are true to the best of my knowledge. I agree to the condition that if any information or statement were found to be wrong, my admission to BITS would automatically be cancelled. I understand that the objective of the Institute will be to examine in detail my educational and professional background along with my employer's visualization of my current and future professional involvement to accommodate my career aspirations within the framework of an appropriate learning avenue. I thus realize that in this process of matching, the Institute instead of rejecting my application for admission may even suggest that I would be more suitable for another degree programme / area of study for which I have not applied. If admitted, I promise to abide by the Rules and Regulations in force or those that may hereafter be made by the Institute and I shall do nothing either inside or outside the Institute which will interfere with its orderly working and discipline. I promise to be regular in the study schedule and in appearing in the examinations at allotted centre. If I am required to come to Pilani for any examination, I shall take permission from my employer for appearing in the same. In the case that I myself will be paying my fees / dues, I affirm that I will regularly pay all fees / dues to the Institute during my programme. Further, in all matters concerning the Institute and myself the decision of BITS Vice-Chancellor shall be binding on me. Place: Signature: 4 of 6

Date:

Name:

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LTV ________________________
SECTION 2: EMPLOYER CONSENT FORM (This section must be duly filled in by all employed candidates) Name of Employing Organization : L & T IES Mumbai Name of Employee Employee Number Designation of Employee : PRASAD HARISH GHOLE : 20006401 : SENIOR SOFTWARE ENGINEER (Date / Month / Year)

Date of Joining your Organization : 09/11/2009 Degree Programme applied for Work Profile of the Employee : Embedded System

: To Design and develop the embedded firmware for Fuel Dispenser Pumps. To analysis requirement and create system specification document.

_______________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ This is to certify that our organization strongly supports and willingly participates in this cooperative effort for conducting the work-integrated learning programme. We feel that this programme will be useful to the employees for their growth and also for our organization. We understand that this programme will be run on the same standard and rigour with which corresponding programmes are run on campus at BITS, Pilani. We agree to give all our cooperation in maintaining its standards. We are willing to participate in this educational process also by nominating a qualified senior professional from our organization / associate organization who will agree to act as a mentor and resource person for strengthening workstudy integration. This mentor will also help in giving suitable organization-based assignments and projects, which will add value to the programme and also will become useful for the organization. Regarding the fees for the programme: (Please tick appropriate box): (a) Our Organization will not pay the fees and dues of the employee. (b) Our Organization will partly pay fees and dues of the employee. (c) Our Organization will fully pay all fees and dues of the employee. Note: If you ticked b, what percentage of the fees would be paid by you: Signature of authorized signatory from organization: Name of authorized signatory from organization: Designation of authorized signatory from organization: Address of the Organization:

Date:

Seal of the organization

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LTV ________________________
CHECKLIST FOR ENCLOSURES / ATTACHMENTS
Important: Please ensure that you have enclosed the following documents / information without which your application will be considered as incomplete and rejected. You must also ensure that the enclosures are appended in the same order as given below. The very first enclosure must be your Degree Certificate issued by your University. Please Tick ( ) against all those items / documents you have enclosed with this application form. 1. Attested Photocopies of B.E. / B.Tech. / M.Sc. / M.C.A. / A.M.I.E. / M.B.A. / BITS B.S. or equivalent degree certificate issued by your university for your educational qualification and spelling of your name. This must be your first enclosure, failing which your application will be rejected. For your date of birth verification attested photocopy of X Pass / Matriculation / Secondary School Leaving Certificate / Marksheet Attested marksheets for all the years / semesters and certificates of all your degree / diploma examinations Experience Certificate(s) towards proof of work experience in current employing organization as well as previous organization(s) wherever applicable. Detailed professional resume of the candidate giving academic & professional achievements including employment details in reverse chronological order. Your detailed work profile duly issued / endorsed by your employer. Details of Research Publications /Patents (if any) submitted by the applicant A write-up on your career objectives in applying to this programme. Any other documents like Certificates for short-term course, marriage certificate / Gazette notification for correct name purpose, equivalence certificate if degree diploma is not from University / State Board, etc. Specify ____________________________________________ Affix 3 copies of your unattested Passport Size Colour Photograph in the space below.

2. 3. 4. 5. 6. 7. 8. 9.

10.

Affix Unattested Passport Size Colour Photograph

Affix Unattested Passport Size Colour Photograph

Affix Unattested Passport Size Colour Photograph

For Office Use Only: Enclosure verification:

Name ______________________________ Signature _____________________________

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BIRLA INSTITUTE OF TECHNOLOGY & SCIENCE, PILANI

INSTRUCTIONS TO APPLICANTS
1. 2. 3. 4.

Application No .LTV

Before filling in this Application Form be sure to carefully read programme details. This Application consists of 2 sections namely, (i) Personal Information & Educational Background, (ii) Employer Consent Form and a checklist. All entries should be filled in neatly and legibly in Capital Letters. Enter your name as given in your Final or Provisional Degree / Diploma Certificate issued by University / Board of Technical Education. In the records of our Institute only this name will be incorporated. Pass certificates given by college or polytechnic will not be sufficient. If your name in our records is to be different from the name as given in your degree / diploma certificate then you must enclose supporting documents such as marriage certificate copy, gazette notification copy etc. You must enclose EQUIVALENCE CERTIFICATE issued by an authority such as Association of Indian Universities (AIU) New Delhi, if degree diploma is not from a University / State Board in India or if obtained from a foreign university / institution, etc. The applicant must ensure that an unattested passport size photograph is duly affixed wherever specified in the application form. Enter your date of birth as given in your matriculation / Secondary School Leaving Certificate or equivalent. Whenever a code letter needs to be entered in a box, specific instructions have been given with the item. However in the case of items with (Y / N), "Y" stands for "Yes" and "N" stands for "No". Enter the appropriate letters (either Y or N) as per instructions given in the specific item. Access to Internet and email would be highly desired in the educational process. You are strongly urged to make efforts to obtain access to Internet and email facilities. When writing your email address in the application form you must be careful about capital / small letters underscore, hyphen, etc.. The applicant should take utmost care when filling the Mailing Address and Permanent Home Address.

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10. If the applicant is employed, the Employer Consent Form should be duly filled in failing which application will be rejected. 11. All the certificates (photocopies) and other attachments / enclosures should be submitted together with application. Such attachments should be properly fastened at the end of application form with a tag or by stapling. Mark all such attachments on the checklist provided at the end of application. Make sure that all enclosures are appended in the same order as in the checklist. On the top right hand corner of each of your enclosures, you must write your Application Number. All enclosure documents should be given in only A4 size paper, which means that you must enlarge or reduce your document size appropriately. 12. Incomplete applications will be summarily rejected. 13. Since every student admitted to an off-campus degree programme is treated as a full time student and as a full time employee, it is essential that the student be not enrolled for any degree or diploma programme, part time or otherwise, in any other university. If it is found that a student is already admitted / registered in some other university for degree/diploma programme, then his admission / registration will be cancelled. __________________________

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