AHT65189924
Birla Institute of Technology & Science,Pilani,Rajasthan
Work Integrated Learning Programmes Division
Application for Admission to [Link]. Automotive Electronics for 2024-25 Sem2
For Office use only
ID No: 2024HT65______ Date of Receipt:_________________
Remarks,if any:________________________________________
Dean Vice-Chancellor
Note:Please read the instructions carefully before filling in this application form.
SECTION 1:PERSONAL INFORMATION & EDUCATIONAL BACKGROUND
[Link]: Kaisarahmed Khatib
[Link]: Male
[Link] of Birth: June 28, 1976
[Link]'s Name: Rashid Ahmed Khatib
[Link]'s Name: Badrunissa R Khatib
[Link]: kaiser@[Link]
[Link]/Phone: +91 85498 77278/+91 83792 62283
[Link]: Indian
[Link] you belong to Scheduled Caste or Scheduled Tribe?[Y/N] ___
[Link] for Correspondence: Jamiya Masjid Street, Hanagal
Dist Haveri
Hanagal,Karnataka,India
[Link] details from School Leaving Certificate onwards in chronological order:
Qualification Name of Year of Total
Subject/Branch Board/University Duration(Years) Division
Level Diploma/Degree completion Marks/CGPA
Graduation or MECHANICAL K.U.D,
B.E. 4 year 1999 6.40 1st division
equivalent ENGINEERING Dharwad
OPERATIONS
Post-Graduation M.B.A. S.M.U, (DDE) 2 year 2017 6.10 1st division
MANAGEMENT
Others
Construction
(including Executive
Equipment NICMAR 6 months 2009 5.70 2nd division
Executive Program
Management
Programs)
10+2 level, 10+2 Level K.S.E.E.B,
MATHEMATICS 2 year 1995 4.90 2nd division
Diploma 3 yr (Intermediate) Karnataka
10th level,
10th Grade 10th D.P.E,
matriculation or 1 year 1992 6.70 1st division
(Matriculation) MATRICULATION Karnataka
equivalent
*As Calculated for declaring result and award of Division by your Board / [Link] marks are not awarded,give Cumulative Grade Point Average Or
its [Link] below the basis on which your B. SC. / B.E. M. SC. / M. C.A. (Or equivalent)final percentage is Calculated (Cleary explain gaps, if
any in a separate Sheet.)
[Link] at which you have studied Mathematics: Graduate Studies (Engg. And Science)
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[Link] you currently enrolled for degree or diploma in any University/Institution: (Y/N) 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.
[Link] you ever been a student of BITS,Pilani.(Yes/No):if yes,please write name of the degree and your ID No.:
[Link] Centre Choice: Bhilwara (Rajasthan)
The evaluation methodology requires admitted students to appear in person at any of the designated exam centres located in Ahilya Nagar / Ahmedabad /
Bengaluru / Bhilwara / Bhubaneswar / Chandigarh / Chennai / Coimbatore / Delhi NCR / Dubai / Faridabad / Goa / Guwahati / Hosur / Hyderabad /
Indore / International / Jaipur / Jamshedpur / Kancheepuram / Kochi / Kolkata / Lucknow / Madurai / Mumbai / Mysore / Nagpur / Pilani / Pune / Surat /
Thane / Thiruvananthapuram / Udaipur / Vadodara / Vijayawada / Visakhapatnam twice during every semester for taking their Mid-Semester and
Comprehensive examinations. These examination sessions will be scheduled on Friday / Saturday / Sunday, and students are responsible for making their own
arrangements to visit any of the designated exam centres located in the above cities to take these exams. Please specify your preferred Examination Centre for
taking the Mid-Semester and Comprehensive examinations from the provided list.
Note: Due to operational reasons, the institute may request the students to appear at an Exam Centre location different from their preferred exam centre choice mentioned above. Additionally, students opting for the
Dubai exam centre will incur an extra exam centre fee, details of which will be provided at the time of admission.
[Link] Employment Status: Employed
[Link] Work Experience: 24 Years 2 Months 2 days
[Link] Experience in Current Organisation: 6 Years 8 Months 4 days
(as on applicable deadline to be counted only from the point of completing BE/MSc or equivalent))
[Link] Details:Since the year of completing BE/MSc or equivalent,give brief employment details below in reverse chronological order.
Name of Employer Designation held Start Date End Date
Al Ayuni Investment and
Maintenance Department Manager Sun 05 Aug 2012 Thu 19 Oct 2017
Contracting Co, KSA
Naba Contracting Est, KSA Workshop Manager Thu 01 Oct 2009 Sun 11 Mar 2012
Yavagal Petroleum, Hangal, India Workshop Manager Tue 10 Feb 2009 Tue 15 Sep 2009
Best Building Company LLC, UAE Workshop Manager Tue 05 Sep 2006 Mon 19 Jan 2009
Dodsal Pvt Ltd, Mumbai, India Maintenance Engineer Tue 01 Jun 2004 Sun 30 Jul 2006
Hindustan Construction Co Ltd,
Mechanical Engineer Thu 07 Nov 2002 Tue 25 May 2004
Mumbai, India
M/s R N Nayak and Sons, Hubli,
Maintenance Engineer Thu 01 Jul 1999 Fri 30 Aug 2002
India
Total Work Experience calculated after completing BE/MSc or
equivalent
Provide the dates of start end of the employment [Link] explain gaps,if any in a separate sheet.
[Link] by the Applicant
I have carefully read the details and instructions given in this application form and declare that all the information 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 information or statements were found to be
wrong, my admission to BITS Pilani would automatically be cancelled. 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 that will interfere with its orderly functioning and discipline. I pledge
to adhere to a regular study schedule and participate in examinations at the exam centre allocated by the Institute. As the person responsible for paying my
fees/dues, I will ensure timely fee payments to the institute throughout the programme. Furthermore, in all matters concerning the Institute and myself, I agree
that the decision of the BITS Pilani Vice-Chancellor shall be binding on me.
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Place:________________________ Signature:_____________________
Date:________________________ Name:
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SECTION 2: EMPLOYER CONSENT FORM (This section must be duly filled in by all employed candidates)
This is to certify that our organisation acknowledges and consents to our employee for enrolling in a work-integrated learning programme with BITS
Pilani to upgrade his/her knowledge and learn new skills. We have no objection to this enrolment and permit the employee to pursue the
programme with the BITS Pilani Work Integrated Learning Programmes (WILP). We expect that this programme has the same rigour as that of a
full-time on-campus programme at BITS Pilani.
The programme will require the employee to leverage work-related problems for their academic projects and learning assignments, only in
compliance with the organisation’s policies and confidentiality requirements.
It will be our endeavour to provide a qualified senior professional from within the organisation, to act as a mentor for strengthening their
work-integrated learning. In case we are unable to provide a mentor from within the organisation, we have no objection to the selection of a mentor
from outside the organisation, as is agreeable to BITS Pilani.
Please note the following details, which are true to our knowledge:
Name of Employing Organization : Larsen and Toubro Construction
Name of Employee: Kaisarahmed Khatib
Employee ID Number: 20161241
Designation of Employee: Deputy General Manager
Date of Joining the Organization: 02-05-2018 (Day/Month/Year)
Degree Programmme applied for: [Link]. Automotive Electronics
Work Profile of the Employee : ___________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Programme fees is being borne by: (Please select only one option)
• The organisation will not pay the fee and dues on behalf of the employee.
• The organisation will partly pay the fee and dues on behalf of the employee.
If yes, please mention the percentage of the fee being paid by the organisation. _________________________________________________
• The organisation will fully pay the fee and dues on behalf of the employee.
Name of the authorised signatory: ________________________________________________________________________________________
Designation of the authorised signatory: ____________________________________________________________________________________
Employee ID number of the authorised signatory: ____________________________________________________________________________
Complete address of the current office location of the signatory: _________________________________________________________________
________________________________________________________________________________________________________________________________
Signature & stamp of the authorised signatory: _______________________________________________
Date: _____________________
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SECTION 3: MENTOR CONSENT FORM
Role of the Mentor:
The basic role of the mentor will be to ensure that the student remains aligned with the academic objectives and the key academic milestones
while pursuing the programme. The mentor’s valuable guidance and professional expertise would also be leveraged to maximise work-integrated
learning and make the education experience highly relevant for the job role and pursuit of the long-term career goals of the student.
Qualifications for a Mentor:
The mentor chosen should be a senior professional with at least 5 years of relevant work experience, holding a B.E./ [Link]./ [Link]./ M.B.A./
M.B.B.S./ First Degree at BITS Pilani or its equivalent. If the mentor has less than 5 years of relevant work experience, then the minimum
educational qualification for the mentor should be M.E./ [Link]./ M.S./ [Link]./ Higher Degree of BITS Pilani or its equivalent is required.
Declaration from the Mentor:
Name of the applicant for whom I will be the mentor: _______________________________________________________
Programme that the applicant has applied for: _______________________________________________________
Full name of the mentor: _______________________________________________________
Designation of the mentor: _______________________________________________________
Highest educational qualification of the mentor, along with specialisation or branch: ________________________________________
Name of the university for the qualification mentioned above of the mentor: ________________________________________
Employer organisation of the mentor: ________________________________________
Total work experience in years and months of the mentor: _______ Years _______ Months
Total work experience in years and months of the mentor, in the current employer organisation: _______ Years _______ Months
Complete address of the mentor: __________________________________________________________________________________
________________________________________________________________________________________________________________________
Contact number of the mentor: ________________________________________
Email address of the mentor: ________________________________________
This is to provide an acknowledgement and acceptance of my role as a mentor for the applicant mentioned above enrolling with BITS Pilani’s Work
Integrated Learning Programme.
I agree to perform the following expected role as a mentor to the applicant if he/she enrols as a student for the above-mentioned programme:
1. Periodically monitor student’s study schedules and submission deadlines for the programme.
2. Provide guidance towards integrating learning from the programme with job role/long-term career goals, especially while the student pursues
their learning assignments and project work.
3. Monitor the student’s progress throughout the duration of the programme. If required by BITS Pilani, also try to be available to engage with the
faculty to collaboratively assess the student’s academic performance and recommend any learning improvement plan.
4. Emphasise the importance of self-study and self-learning throughout the programme to the student.
Signature of the mentor: _______________________________________
Date: __________________
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MANDATORY SUPPORTING DOCUMENTS
To complete the application submission process, candidates are required to submit copies of supporting documents through the Application
Centre.
Before uploading scanned copies of the mandatory supporting documents listed below, please ensure that they are complete in all respects, failing
which your application will be considered as incomplete and rejected. Please SELF ATTEST all academic mark-sheets and certificates using
your FULL SIGNATURE.
For certain documents such as marksheets where multiple pages may need to be uploaded, you may scan multiple pages into a single
pdf file and upload it. Alternatively, you may scan different pages as separate pdf files, then create a zip file of these pdf files and upload
it as a single zip file.
Documents to be uploaded
1. Application Form: This implies pages 1 & 2 of the downloaded pdf of the Application Form. Upload a single pdf file containing the two pages scanned together,
or a zip file that has separate pdf files for each page. Ensure that all additional information required therein has been filled legibly by hand, and photograph
and signature are present.
2. Photograph: Upload a soft copy of a professionally taken passport-sized photograph.
3. Employer Consent Form: Upload scanned copy of page 3 of the downloaded pdf of the Application Form. Ensure that all additional information required
therein has been filled legibly by hand, and signatures and company stamp are present.
4. Mentor Consent Form: Upload scanned copy of page 4 of the downloaded pdf of the Application. Ensure that all additional information required therein has
been filled legibly by hand, and signatures are present.
5. Degree Certificate(s): Upload scanned copy of BE/ [Link]./ [Link]./ MBA/ AMIE/ BITS Pilani B.S. or equivalent degree certificate that includes your name as it
is spelt. Upload all certificates together as a multi-page pdf, or a zip file. Self attest all the scanned pages.
6. Proof of Date of Birth: Upload a photocopy of your 10th Pass/ Matriculation/ Secondary School Leaving Certificate/ Marksheet clearly stating your date of birth.
7. Marksheet(s): Upload academic marksheets for all years/ semesters of all your degree/ diploma examinations. Upload all marksheets together as a multi-page
pdf, or a zip file. Self attest all the scanned pages.
8. Proof of Work Experience: For the current organisation, please upload a work experience certificate issued by the company HR. For previous organisations,
you may upload work experience certificates if available, or else submit the Appointment Letter along with the Relieving Letter. Upload all work experience
certificates as a multi-page pdf, or a zip file.
9. Company Brochure: Upload latest brochure giving detailed profile of the current employing organisation. In case the brochure is not available, upload copy of
the company profile as given on the company website.
10. Career Objective: Upload scanned copy of a write-up on your career objectives in applying to this programme.
11. Mentor Resume & Degree Certificate: Upload copy of detailed resume of your proposed Mentor along with an attested photocopy of his/ her highest degree
certificate. Upload a multi-page pdf, or a zip file.
12. Letter of Recommendation: If you are currently working for a University or an educational institution, upload a letter of recommendation from the head of the
institution, such as Vice Chancellor or Registrar of the University. Only those candidate who work with educational institutions are required to submit this
document.