Indian Institute of Technology Kharagpur

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1 MEDICAL EXAMINATION REPORT (to be issued by a Registered Medical Practitioner) Annex-1 General Expectations Candidates should have good general physique. In particular, a) Chest Measurement should not be less than 70cm, with satisfactory limits of expansion and contraction. b) Vision should be normal. In case of defective vision, it should be corrected to 6/9 in both eyes or 6/6 in the better eye. Colour blind or uniocular persons are ineligible for admission in Mining Engineering and Mining Machinery engeneering courses. c) Hearing should be normal. Defective hearing should be corrected. d) Heart and lungs should not have any abnormality and there should be no history of mental illness or epileptic fits. PERSONAL HISTORY 1. Name Roll No Parent/Guardian's Name Age...Years...Months 5. Sex Identification mark on the body. if any (This can be a mole, scar or birthmark) Major illness / operation, if any (specify nature of illness / operation)... MEDICAL CERTIFICATE (the following are to be filled by the Medical Officer conducting the medical examination) Signature of the Candidate 1. Height...cm 2. Weight...kg 3. Past History (a) Mental Disease... (b) Epileptic Fit Chest (a) Inspiration...cm (b) Expiration...cm 5. Blood Group Hearing Vision with or without glasses (a) Right Eye... (b) Left Eye... (c) Colour Blindness... (d) Uniocular Vision Respiratory System Nervous System Heart: (a) Sounds... (b) Murmur Abdomen (a) Liver... (b) Spleen (a) Hernia... (b) Hydrocele Any other defects CERTIFIED that...son / daughter of... (a) fulfills the prescribed standard physical fitness and is FIT for admission to Engineering / Architecture / Pharmaceutics / Science Course (b) does not fulfill the prescribed standard of physical fitness and is unfit / temporarily unfit for admission due to following defects... (c)... Signature of the Medical Officer Date... Full Name... Medical Registration No... Official Seal

2 DECLARATION TO BE PROVIDED BY THE GUARDIAN OF THE STUDENT AT THE TIME OF ADMISSION Annex-2 I Father / Guardian of Mr./Ms hereby declare the following in respect of my ward to be admitted to B.Tech./M.Tech./MS/Ph.D. Programme of study at IIT Kharagpur. I am aware of the fact that the B.C.Roy Technology Hospital located in the campus and run by IIT Kharagpur for its community has limited facilities and may not be adequate for prolonged treatment of my patient with chronic or serious ailments and it is the responsibility of the guardians to take care of their wards for outside treatment. SIGNATURE OF THE GUARDIAN COUNTER SIGNATURE OF THE STUDENT

3 Annex-3 Undertaking from the Students I, Mr./Ms...., Roll No.:... Programmme:...Dept...Student of Indian Institute of Technology Kharagpur do hereby undertake on this day...month... year..., the following : 1. I shall abide by the admissible rules and regulations of IIT Kharagpur and follow the code of conduct for students. I acknowledge that the institute has the authority of taking disciplinary action on me for non-compliance of the same. 2. That I have read and understood the directives of the Hon'ble Supreme Court of India on antiragging (available at 3. That I understand the meaning of Ragging and know that the ragging in any form is a punishable offence and the same is banned by the Court of Law. I understand that, in case I am involved in ragging, the case will be reported to the police and the Law will take its own course and I will be summarlly expelled from the institute. 4. That I have not been found or charged for my involvement in any kind of ragging in the past. However, I undertake to face disciplinary action / legal proceeding including expulsion from the institute if the above statement is found to be untrue or the facts are concealed, at any stage in future. 5. That I shall not resort to ragging in any form at any place and shall abide by the rules/laws prescribed by the Courts, Goverment of India and the Institute authorities for the purpose from time to time. 6. I understand that as per rules and resolution of the Institute, I will not be permitted to possess or use any motorised vehicle inside the Institute campus, unless I am permitted to do so by a written authorisation from the Dean (Student's Affairs). 7. I also declare that I am not suffering from any serious/contagious ailment including psychology related symptoms. Signature of Student I hereby fully endorse the undertaking made by my child / ward. Signature of Mother / Father and or Guardian

4 INDIAN INSTITUTE OF TECHNOLOGY KHARAGPUR ACADEMIC (PGS&R) SECTION Annex-4 FORMAT OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR ADMISSION TO CENTRAL EDUCATIONAL INSTITUTIONS (CEIs), UNDER THE GOVERNMENT OF INDIA This is to certify that Shri/Smt./Kum. Shri/Smt. Village/Town District/Division State belongs to the backward class under: in the Son/Daughter of of Community which is recognized as a i. Resolution No /68/93-BCC(C) dated 10/09/03 published in the Gazette of India Extraordinary Part I Section I No. 186 dated 13/09/93. ii. Resolution No /9/94-BCC dated 19/10/94 published in the Gazette of India Extraordinary Part I Section I No. 163 dated 20/10/94. iii. Resolution No /7/95-BCC dated 24/05/95 published in the Gazette of India Extraordinary Part I Section I No. 88 dated 25/05/95. iv. Resolution No /96/94-BCC dated 9/03/96. v. Resolution No /44/96-BCC dated 6/12/96 published in the Gazette of India Extraordinary Part I Section I No. 210 dated 11/12/96. vi. Resolution No /13/97-BCC dated 03/12/97. vii. Resolution No /99/94-BCC dated 11/12/97. viii. Resolution No /68/98-BCC dated 27/10/99. ix. Resolution No /88/98-BCC dated 6/12/99 published in the Gazette of India Extraordinary Part I Section I No. 270 dated 06/12/99. x. Resolution No /36/99-BCC dated 04/04/2000 published in the Gazette of India Extraordinary Part I Section I No. 71 dated 04/04/2000. xi. Resolution No /44/99-BCC dated 21/09/2000 published in the Gazette of India Extraordinary Part I Section I No. 210 dated 21/09/2000. xii. Resolution No /9/2000-BCC dated 06/09/2001. xiii. Resolution No /1/2001-BCC dated 19/06/2003. xiv. Resolution No /4/2002-BCC dated 13/01/2004. xv. Resolution No /9/2004-BCC dated 16/01/2006 published in the Gazette of India Extraordinary Part I Section I No. 210 dated 16/01/2006. xvi. Resolution No /14/2004-BCC dated 12/03/2007 published in the Gazette of India Extraordinary Part I Section I No. 67 dated 12/03/2007. xvii. Resolution No /2/2007-BCC dated 18/08/2010. xviii. Resolution No /13/2010-BCC dated 08/12/2011. Shri/Smt./Kum. family ordinarily reside(s) in the and / or his/her District/ Division of State. This is also to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the Government of India, Department of Personnel & Training O.M. No /22/93-Estt. (SCT) dated 08/09/93 which is modified vide OM No /3/2004 Estt.(Res.) dated 09/03/2004 and further modified vide OM No /3/2004-Estt. (Res.) dated 14/10/2008 and further modified vide OM No /1/2013-Estt (Res.) dated 27/05/2013 or the latest notification of the Government of India. Dated: Seal District Magistrate / Deputy Commissioner/ Competent Authority Note: a) The term 'Ordinarily' used here will have the same meaning as in Section 20 of the Representation of the People Act, b) The authorities competent to issue Caste Certificates are indicated below: i. District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional Deputy Commissioner / Deputy Collector/ 1st Class Stipendiary Magistrate / Sub-Divisional magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank of Ist Class Stipendary Magistrate). ii. Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate. iii. Revenue Officer not below the rank of Tehsildar and iv. Sub-Divisional Officer of the area where the candidate and / or his family resides. The date of issue of OBC (NCL) certificate should be on or after 1st April 2017

5 Annex-5 This Certificate must be furnished by a sponsored candidate at the time of Joining a programme SPONSORSHIP CERTIFICATE Certificate that Mr./Ms. an applicant selected for admission to the Post-graduate / Research (Ph.D.) programme in the Deparment / Centre / School of the Indian Institute of Technology, Kharagpur in the Autumn (July) / Spring (January) Semester of the session is employed with our organization named and that he / she has been sponsored by us for undergoing the programme : following are the relevant particulars, concerning him / her : (1) Date of joining with the organization : (2) Nature of appointment : (a) Permanent (b) Temporary for years, or Contract, valid upto (3) Present Designation Nature of duty (4) Present place of posting (5) Period of sponsorship granted, from to (6) Date of being relieved of duties to join the programme in the Institute (7) Total period of leave granted by the organization Year Months Days for undergoing the programme (Residential requirement) (8) Kind of leave granted : (a) with full pay, from to (b) with half-pay, from to (c) without pay, from to (9) In the case of candidates who intend to apply, after enrolment in the Institute, for permission to work externally at the place of employment whether :- (a) Neccssary research facilities are available in the organization (b) The organization agrees to provide him / her those facilities (c) Name & Designation of the expert in the organization can guide partly research work in this case if necessary (with a brief bio-data) Certified further that his / her services with the Organization will be retained during the period he / she carries out the studies / research work at IIT, Kharagpur and on campletion thereof he / she will be accepted for joining back. It has been noted for the sponsored students / scholars the Institute does not have any financial commitment whatsoever and all necessary expenses for his / her stay and study / work there be borne by (a) himself / herself, (b) the Organization, (c) partly himself / herself and partly the Organization. In the event of there being any outstanding dues in the Institute on his / her account we agree to arrange for the recovery thereof. Date Signature of Competent Authority Full Name Designation : : Official Stamp : N.B.: Please strike out the items not applicable. All the columns must be filled in otherwise the Sponsorship Certificate will not be acceptable.

INDIAN INSTITUTE OF TECHNOLOGY ROORKEE ROORKEE Admission to PG Programme-2018

INDIAN INSTITUTE OF TECHNOLOGY ROORKEE ROORKEE Admission to PG Programme-2018 CHECK LIST Name of student Prog. Code. Deptt:..... Please fill the required information, paste photographs wherever necessary,