Swami Rama Himalayan University (Established U/S 2 (f) of UGC Act 1956 vide Uttarakhand Act No. 12 of 2013) Swami Ram Nagar, P.O. Doiwala, Dehradun- 248140 Uttarakhand Ph: 0135-2471600

Application Form for Admission to Ph.D. Programme

PERSONAL DATA Name (in block letters) Father’s/ Husband’s Name Date of Birth (DD/MM/YYYY) Sex

Male

Female

Affix your recent passport size colour photograph

Transgender

Res:

Phone

Mobile:

E-mail Nationality Permanent Resident of Uttarakhand State of Domicile & Category

Yes No Categories UK-GEN  UK- ST  UK-SC  UK-OBC  Sub-categories PH  DPW  FF  Others  Category (SC / ST / OBC / PH/ Kashmiri Migrant)

Permanent Address with PIN Code and Phone No. Present Address with PIN Code and Phone No. Address for Correspondence (Please tick  in the relevant box)

 Permanent

 Present

ACADEMIC RECORD (attach photocopies) : Examination Passed

Title of Degree/Certificate

Name of Institution/Board / University

Duration From - To

Year of Passing

Aggregate Marks (%)

Division Obtained

X Class XII Class Graduation Post Graduation Others NOTE: Candidates having their Master’s degree from foreign University are required to submit equivalence certificate.

WORK EXPERIENCE (attach photocopies) : Period of Service (from-to)

Employer’s Name and Address

Position

Area of Work

NET, ICMR, CSIR, GATE and other fellowship exam details (attach photocopies) : Exam. Name

Exam. Discipline

Score

Exam. Year

AWARDS AND RECOGNITION (List distinctions, honors, scholarships and awards) attach photocopies: Awards

Date

Basis of Selection

RESEARCH PUBLICATIONS AND/OR BOOK(S) AUTHORED/EDITED, IF ANY If “Yes” , please give details.

Yes

No

(If space is not sufficient, please attach the details on a separate sheet)

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ SEMINARS/CONFERENCES/WORKSHOPS ETC. ATTENDED, IF ANY If “Yes” , please give details.

Yes

No

(If space is not sufficient, please attach the details on a separate sheet)

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

ARE YOU AN EMPLOYEE OF CENTRAL GOVT./STATE GOVT./PSU/AUTONOMOUS BODY : Yes

No

If “Yes” , please give name and address of the Department/Institution/Organization, your date of joining and your present designation. (attach No Objection Certificate from your employer) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ARE YOU AN EMPLOYEE OF SWAMI RAMA HIMALAYAN UNIVERSITY

Yes

No

If “Yes”, please give the name of the Constituent College/Academic Unit. (attach letter of the Principal/Head of the Constituent College/Academic Unit commenting on your suitability for the program):

ARE YOU A FOREIGN NATIONAL

Yes

No

(Foreign nationals are required to follow the norms and procedures as prescribed by the Government of India / University Grants Commission or any other Authorities / Bodies.)

NAME AND ADDRESSES OF TWO REFEREES (Not being relatives). Both the referees should have knowledge of academic experience record of the applicant: A. Name: Mr. /Ms …………………………………….…

B. Name: Mr. /Ms ………………………………………….

Qualifications………………………………………..

Qualifications……………………………………….…..

Organization ………………………………………..

Organization …………………………………….……..

Designation ………………………….………………

Designation ………………………………………….…

Mailing Address……………………………….…….

Mailing Address…………………………..……………

Tel. No. with STD code ……………..………………

Tel. No. with STD code ………………………………

Cell No……………………………………….………..

Cell No……………………..…………………………..

E-mail: ………………………………………………..

E-mail: ………………………………….……………..

DETAILS OF APPLICATION PROCESSING FEE (Demand Draft for a sum of Rs. 1,000/- drawn in favor of “Swami Rama Himalayan University” payable at State Bank of India, Jolly Grant {Bank Code no. 10580}, Dehradun): DD No. and Date : ……………………………………………………………………………………...…. Name of issuing Bank with branch : ………………………………………………………………….. Amount (Rs) : ………………………………………………………………………………………………

PROPOSED RESEARCH AREA Area of Interest

Specialty/Discipline

 Biochemistry  Management  Nursing

 Microbiology  Rural Health

 Applied Sciences & Humanities  Engineering & Technology

DECLARATION I certify that I satisfy all the requirements of the PhD program of Swami Rama Himalayan University. I hereby declare that all the particulars stated in this application are true to the best of my knowledge and belief. I also understand that the decision of the Admissions Committee regarding my admission will be final.

Place:

Date:

Enclosures:

Signature of Applicant