Application Form For SURGE 2018 For IITK students at IITK

Full Name:
Gender:
Guardian's Full Name: 
Date of Birth
(As per official records ):
PRESENT ADDRESS PERMANENT ADDRESS*: Same as Address for Present Mailing
Address (Click if applicable)
Address 1: 
Address 1: 
Address 2: 
Address 2:
City: 
City: 
State: 
State: 
Pincode: 
Pincode: 
PROGRAM CATEGORY

Please consider my application in categories mentioned below (more than one option can be chosen)
Institute Funded
Self Funded
Project Funded
Industry IITK Tie-Up
CONTACT DETAILS AFFILIATED ENROLLMENT DETAILS
Hall of Residence:
Institute Name:
Room No: 
Roll No:
Cell No: +91
Program of Study: 
Phone No: +91
Department:
Email Id: 
@iitk.ac.in
Year of Study:
Cumulative Performance Index
(CPI): 
/Out of:
EMERGENCY CONTACT DETAILS
Name: 
Email: 
Phone No: +91
RECOMMENDER ONE RECOMMENDER TWO
*(People familiar with your academic work)
Name: 
Name: 
Contact No: 
Contact No: 
Email: 
Email: 
Designation: 
Designation: 
MENTOR DETAIL
Name: 
Department: 
Email: 
Contact No: 
Upload passport size recent photograph (Photo should be in jpg format)
* Maximum File Size allowed : 1 MB
So, please check the size of image before uploading.
 

PROPOSED RESEARCH (A one page document not exceeding 500 words detailing what broad area you want to work, and a specific research problem that you want to undertake in 8 weeks. Note that depending on the interest of your mentor, you may end up working on a different problem.)In case you are a MTech student please upload title and synopsis of your thesis.
Marks/TRANSCRIPTS(scanned or soft copy)*Current
Scanned copy of Two Letters Of Recommendation (as per the prescribed format mentioned on website)
Scanned copy of Mentor Certification (as per the prescribed format mentioned on website)

Upload PDF
Verification code:*
STUDENT DECLARATION:

I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. In the event of the information being found false or incorrect or any ineligibility being detected before or after the selection, my candidature is liable to be cancelled and action initiated against me.