Award/ Fellowship



Application for BIRAC Innovation Fellowshipunder University Innovation Cluster (UIC)ANNA UNIVERSITY, CHENNAIThis Application is divided into 6 parts: Personal profile, Educational qualification, Master/Doctoral work, Professional experience, References and Project Proposal.*Fields are mandatory.Personal Profile:*Applicant TypeGovt. EmployedPrivate EmployedOther (Mention present status)*Applicant NameFirst NameMiddle NameLast NameDate of BirthDD/MM/YYMarital StatusSingle/Married*GenderMale/FemaleDo you belong to SC/STYes/NoContact Details:*Present AddressAddress City/State/PincodeCityStatePincodeTel (With STD Codes) HomeTel (With STD Codes) WorkCan we contact you at workYes/NoMobileEmailPermanent Address (if different from present address)AddressCity/State/PincodeCityStatePincodeEducational Qualification:Please list in chronological order, starting from matriculation onwards.Name of the Examination/DegreeUniversity/ BoardDivision/GradeField of study / Subject/s Date of passingPlace/CountryMaster’s Research Work/Doctoral WorkPublications Authored/Co-Authored/Edited. Please list starting from latest (Please attach a copy in word/pdf format) Name of JournalImpact factor (Thomson reuters)/ ISSN No.Publication Type (Review/ Research) Vol , Page number & Year of PublicationBook or Book Chapters Authored/Edited Name of PublicationImpact factor (if any)/ ISBN No. Date of PublicationPublication TypeTitle of the Article Seminars/Conferences/Symposia Attended NamePlaceNational/ InternationalWhether presented a paperoralPosterPatents Filed/GrantedTitle of the PatentPatent Application No.Inventor Name/sPatent No. (if Granted)Technology AreaBrief note on commercial feasibility (not more than 150 words)Any other Industry training program attendedName of the ProgramSpecialized AreaDateAward/ FellowshipS. No.DetailsResearch Projects completed/ in ProgressResearch UndertakenS. No. Title of the ProjectFunding AgencyDuration on yearsAmount sanctionedProfessional Experience: (Latest employment to the first employment)Dates (Month/Year)Location/CountryEmployer Name1/ AddressPosition Held (with scale of pay, if in service)Responsibilities Dates (Month/Year)Location/CountryEmployer Name 2/ AddressPosition Held (with scale of pay, if in service)Responsibilities Continue on the table if necessaryReference (at least two referee’s ):May we request a reference?Before offer of FellowshipAfter offer of FellowshipName 1Job Title/PositionTelephoneAddress Email & mobile No.Please indicate if this is a work reference or an academic referenceWork ReferenceAcademic ReferenceName 2Job Title/PositionTelephoneAddressEmail & mobile No.Please indicate if this is a work reference or an academic referenceWork ReferenceAcademic ReferenceName 3Job Title/PositionTelephoneAddressEmail & mobile No.Please indicate if this is a work reference or an academic referenceWork ReferenceAcademic ReferenceProject Proposal:Broad Research Area (Tick one)Bioprocess TechnologyHealthcare diagnosticTitle of the Proposed Project Specific areaObjective Need(1000 words maximum)Commercialization approach(1000 words maximum)Milestones (six months each) with relevant deliverables Envisaged outcome at the end of the project (Technology licensing/ Start up)Any industry / mentor collaboration (Is there any already identified partner / mentor? If yes, please provide the details)Declaration:I declare that the information I have provided in this application form, to the best of my knowledge and belief, is correct and complete.If I include any details that you know to be false or if I withhold relevant information, I may render myself liable to disqualification form the recruitment process or, if awarded the fellowship, to withdrawn.Name of the ApplicantSignatureDate:Please note: Kindly ensure that all the required information is enclosed. It may not be possible to consider a candidate for want of complete information. ................
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