Application Form Print | Internship Application

Application Number: INT/MS/SUM14/XXXX Applied Date: DD-MM-YYYY

1) Name of the Applicant

MS. DEXTER ALLISON

2) Internship Type

Summer

3) School

Mechanical Sciences

4) Area/Topic of interest

Modeling and Optimization of Manufacturing Systems

5) Duration
(Not below tree weak and not exceeding eight)

01-12-2015 To 31-12-2015

6) Source of Finance

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7) Duration of Finance

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8) Amount per month

1500

9) Name of the Institution/ University
(To which the student belongs)

Harrison Salazar

10) Institution Address

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11) Department/ School

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12) Degree Pursuing

B.Tech.

13) Current Semester/Year

Semester 3

14) Programme Duration

4 years

15) Subject Specialization

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16) Name and Contact Details of HOD/HOS

Name

Alea Marshall

Address

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Email

zavutezof@yahoo.com

Phone

9356658852

17) Category

SC

18) Gender

Female

19) Mother's Name

Nichole Harper

20) Father's Name

Courtney Gaines

21) Nationality

INDIAN

22) Religion

MUSLIM

23) Marital Status

Married

24) If Person with Disability

NO

25) Type of disability

NA

26) Address Details

Address for Correspondence B-57, 5nd Floor, SECTOR 6, NOIDA, U.P, PIN: 320663		Permanent Address B-57, 5nd Floor, SECTOR 6, NOIDA, U.P, PIN: 320663
Mobile No. XXXXXXXXXXXX		Phone No. XXXXXXXXXXXXXXX

Examination Passed	Board/University	Year	Subjects/ Discipline/ Specialization	Division/ Class	%Marks / CGPA / Equivalent
27) Educational Qualification (Starting from 10th onwards and upto last degree obtained)
HSC	Central Board of Secondary Education	2008	NA	1	89
+2	Council of Higer Secondary Education	2010	Physics, Checmistry, mathematics	1	80

28) Any Other information
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29) List of Attachments

(1) Photograph (2) Signature (3) Transcript (4) Resume (5) Bonafide Certificate (6) Identity Card (7) 10th Certificate (8) 12th Certificate

30) Health Declaration

Do you have any physical illness or have you been currently undergoing any medical treatment/ been treated/ been diagnosed of any illness which may affect your studies? NO

Do you have any chronic (long lasting or persistent) medical condition that requires treatment or medication? NO

N.B.: Any medical expenses during the internship period will be borne by the candidate himself/herself. IIT Bhubaneswar will not be responsible towards any medical expenses. However medical facility is available in IIT Bhubaneswar campus

31) Criminal/Disciplinary Offence

Have you been convicted of any criminal offence by a court of law in any country? NO