Application form
For Internship/Dissertation/Project Work at CSIR-NEIST, Jorhat-6
1 Name of the student (in Block letters)
Passport
2 Father’s/Mother’s name Photograph
3 Date of birth (DD/MM/YYYY)
4 Nationality
5 Religion
6 Sex Male/Female/Others
7 Category SC/ST/OBC/UR / PWD
8 Address for communication
(in block letters)
9 Mobile No.
10 Email address (in block letters)
11 Course undertaken Semester / Year:
(Specialization /Stream/ Branch, in case
of M Sc/ B Tech etc.)
12 Name of the Institute / College / University
13 Name of the Affiliated University
14 Address of the Institute/ College
15 Expected period of proposed internship From…………….…………………… To……………………………………..
training/ dissertation/ project work
16 Nature of Work Internship / Dissertation/ Project Work
17 Educational /Professional/ Technical Qualification ( from 10th onwards)
Examination Name of the Duration of Year of % of Marks Division/ Subjects /
Passed Board/University Degree/ Passing Class Specialization/ Branch
Diploma
10th
12th
18 Are you ward of any CSIR-Employee Yes / No If yes, name of the employee:
Designation, Division, Institute
19 Preferred Department/ Centre/ Scientist of
CSIR-NEIST, if any
20 Declaration: I hereby declare that all the entries made by me in this application are true to the best of my knowledge and belief
Place
Date
Signature of the Applicant