Application No:

CIPET: INSTITUTE OF PLASTICS TECHNOLOGY (IPT)

(Dept. of Chemicals & Petrochemicals, Affix a recent passport size
Ministry of Chemicals & Fertilizers, Govt. of India) photograph duly attested by
Affiliated to the University of Madras a gazette officer
TVK Industrial Estate, Guindy, Chennai – 600 032
Ph: 044-22254710, 9677123885, 9841261880. Web: www.cipet.gov.in
Head Office: Guindy, Chennai - 32

Application Form for Academic Session 2018-19

M.Sc. Applied Polymer Science

Please furnish all the required information. Clearly indicate, ‘not applicable’ wherever necessary.
(To be filled in by the candidate in his/her own hand writing legibly in block letters in English)

1. Name of the applicant: (as per SSLC/Matriculation Certificate)

2. Date of Birth : (DD/MM/YYYY)

3. Sex : Male Female

4. Blood Group :----------------------------------------------------------------------------------------------
5. Mother Tongue :----------------------------------------------------------------------------------------------
6. Native Place :----------------------------------------------------------------------------------------------
7. District and State :----------------------------------------------------------------------------------------------
8. Nationality :----------------------------------------------------------------------------------------------
9. Religion :----------------------------------------------------------------------------------------------
10. Community : OC BC MBC Minorities SC SC(A) ST
11. Differently Abled :----------------------------------------------------------------------------------------------
12. Aadhar No. :----------------------------------------------------------------------------------------------
13. Name of the Father/ Guardian :------------------------------------------- Occupation :--------------------------------
14. Name of the Mother :------------------------------------------- Occupation :--------------------------------
15. Annual Income :-------------------------------------------
16. Address for Communication :----------------------------------------------------------------------------------------------
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Parents Mobile No :----------------------------------------------------------------------------------------------
Parents E-mail id :----------------------------------------------------------------------------------------------
17. Permanent Address :----------------------------------------------------------------------------------------------
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18. Details of the Qualifying Examination UG (10+2+3)

(a) Name of the Degree with subject :-----------------------------------------------------------------------------------

i. Pattern of the Course : Semester Non – Semester

ii. Medium of the Study :-----------------------------------------------------------------------------------

iii. Month and Year of Passing :-----------------------------------------------------------------------------------

(b) Name of the College :-----------------------------------------------------------------------------------

(c) Name of the University :-----------------------------------------------------------------------------------

(Applicant from other universities, should obtain Eligibility Certificates from the University of Madras if selected)

(d) Register Number :---------------------------------------------------------

Marks Maximum
Subject in B.Sc. Degree Percentage Class
Obtained Marks

Part I: Language - --------------------------

Part II: English

Part III: (Theory + Practical)

(Excluding NCC, NSS etc.)
Core* : -----------------------------------
Allied I : ------------------------------------
Allied II : ------------------------------------

Overall Percentage (Part III only)

* (If final semester results are not published, fill upto V semester and final semester mark sheet copy shall be sent before 08.06.2018)

19. Extra Curricular Activities (if any) :--------------------------------------------------------------------------------------------

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20. Application Fee Details
(DD for Rs.300/- (Rs. 150/- for SC/ST) drawn in favor of CIPET, Chennai, payable @ Chennai)

Challan / DD. No : -----------------------------

Dated : -----------------------------
Drawing Bank : -----------------------------
21. Details of Subjects and Marks Obtained in the Qualifying Examination:

Subjects No. of Attempts Marks secured Max. Marks % of Marks

Part I:
1
2
3
4
Class in Part I : Total in Part I

Part II:
1
2
3
4
Class in Part II: Total in Part II

Part III (Main, Elective & allied / ancillary subjects with Practicals)*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Class in Part III: Total in Part III

* (If final semester results are not published, fill upto V semester and final semester mark sheet copy shall be sent before 08.06.2018)
22. Certificate Copies to be Enclosed :

i. Birth Certificate
ii. Community Certificate
iii. Transfer Certificate
iv. H.S.C Mark Statement
v. UG Mark Statements

Declaration of the Applicant

I hereby declare that the information furnished above are true and correct to the best of my knowledge. In case, the same are
found incorrect at a later date, the admission can be cancelled.

Place :

Date :

Signature of the Applicant

INSTRUCTIONS

1. Please read the Prospectus carefully before filling in the Application

2. Applications must be complete in all respects. Incomplete Applications will be summarily rejected. All columns
must be filled in with relevant information.
3. In the case of students withdrawing from programme after admission, NO REFUND OF FEE will be made by the
CIPET under any circumstances.
4. Copy of the certificates to be attached for items 1, 2, 10, 11, 18 & 19 for evidence.
5. The dully filled in application should be sent to the Principal Director & Head, CIPET, Chennai – 600 032 on
or before 08.06.18.
6. The students are requested to furnish the following information when they submit the Demand Drafts for the fee
payable by him/her. The following information may be furnished on the reverse side of the Demand Draft.
(i) Name of the student, (ii) Degree/Course, & (iii) Purpose of the payment.