Maulana Azad National Institute of Technology, Bhopal
Application Form
‘Impact’ Internship for MANIT Girls on Merit-cum-Means
Paste Your
Photograph
* Full Name: ………………………………………………………………………………
* Year of Admission in B.Tech.: ………………* Branch: ………………………………………………
* Scholar No.: …………………………….. * Contact No: …………………………………….
* Email ID: ……………………………………………………………………………………..
* Date of Birth: …………………………………………………………………………………
* Father / Guardian's Name: ……………………………………………………………………
* Present Address: ………………………………………………………………………………
.
……………………………………………………………………………….
* Permanent Address: ………………………………………………………………………….
…………………………………………………………………….........
* Guardian's/ Father Occupation : ………………………………………………………………………
* Total Family Income (INR Per Year): ……………………………………………………………….
(Please Attach PDF of latest Income certificate)
* Please mention Semester wise CGPA
(Attach PDF of all the Semester mark sheets)
S. No. Semester CGPA
1 Semester I
2 Semester II
3 Semester III
4 Semester IV
You’re Special Academic Achievement (if any): …………………………………………………………..
…..………………………………………………………………………………………………………..……..
…………………………………………………………………………………………………………………..
(*) - Incomplete applications will not be considered, nor will these applicants be interviewed.
DECLARATION: I hereby declare that; I will not ask for any academic relaxation for doing the internship and all
the statements made in this application are true and complete and nothing has been concealed/ distorted. I am aware
that, if at any time I am found to have concealed/distorted any material information, my engagement is liable to be
summarily terminated without any notice.
Date: Applicant Signature:
Name & Signature of HoD
