Indian Institute of Technology Indore

Khandwa Road, Simrol

Indore 453 552

Application Form for Summer Internship 2020

Name: ______________________________________________________________________

Department: _________________________________________________________________
Please affix a
Institution/College with Address: _______________________________________________
recent passport
_________________________________________________Pin Code: _________________
size
Address for Correspondence: ____________________________________________________ photograph

____________________________________________________Pin Code: _________________

Mobile No.:_______________________________ Email: ______________________________

Date of Birth: (DD/MMM/YYYY)_________________________ Gender: (Male/Female) ___________________

Qualification (in reverse chronological order)*

Degree Branch Year of College/University Institution % of marks

Specialization passing obtained

Faculty Advisor name: _____________________________________________________________________

(To be selected from the list available at the link Faculty advisor and Internship Areas)

Area of Internship: _________________________________________________________

Internship Duration: _____________ to ___________ (DD/MMM/YYYY)

Accomodation required: YES/NO ________ Duration: ___________ to __________

Internship Registration Fees: Rs 5000/-

Laboratory Charges: Rs ____________________ Total amount paid: ______________________

Payment details: __________________________________________________________________

1
Declaration:

I, _____________________declare that all the information given by me in the application form is correct.
I, have gone through and I will abide by the the Internship Policy of IIT Indore.

Place:

Date:

Signature of the Intern

No Objection Certificate

Ms./Mr.__________________________________ studying in the _______________________________

department/centre of ________________________________ at _________________________________

_____________________________________________________________________________ is hereby

permitted to attend the Summer Internship 2020 at Indian Institute of Technology Indore. This Institute/

College has no objection for attending the Summer Internship 2020 from ___________ to ____________.

Date: Signature & Seal of Head of the Institution/College

The interns are requested to please fill in the details and email the duly signed application form to
dorgoffice@iiti.ac.in. All the fields in the form are complusory to be filled. Incomplete forms will not be
accepted