Ministry of Science and Technology Department of Science and Technology

WOMEN SCIENTISTS SCHEME (WOS- ! "esearch in #asic$ pplied Sciences

S%#&ECT CODE'
Physical Sciences
I

#"E ( IN C "EE"' NO

DEC) " TION #* THE C NDID TE

I have gone through the fellowship rules and conditions of the award and if selected, I agree to abide by them. The particulars given in the form are correct and I am prepared to present myself for presentation/discussion, if called upon to do so.

Date:

Signature of the Candidate

SECTION + ,ENE" ) IN-O"M TION

1 . 2 . 3 . 4 . 5 . Name (in Block Letters) Husband/Fathers name Postal address for correspondence E-mail (mandatory) Permanent address : Sarita Sambhaji Nikam : Sambhaji Hariba Nikam : 1823/11, Gandhi : saritanikam88@gmail.com : 1823/11, Gandhi Vikas Nagar,

Galli no. 2, Kabnoor, Ichalkaranji 6 . 7 . 8 . Date of Birth Whether belong to SC/ST/OBC/PH (Attach copy of the relevant certificate) Married/Unmarried Academic record (from matriculation onwards): : Unmarried : 26/01/1990 : No

9.

Sr.No.

Degree

Period of Study From - To

Board/University/ Institute

Subject

Marks (%)

1 2 3 4 10.

S.S.C H.S.C B.Sc. M.Sc.

2004-2005 2006-2007 2007-2010 2010-2012

Pune Pune Shivaji Unive !i"# Shivaji Unive !i"#

All PCMB Ph#!ic! Ph#!ic!

84.53 67.50 80.12 67.33

Scholarships, Medals, Fellowships, Awards, Distinctions or Honors received during your University/academic career : No Whether passed examinations conducted by NET/GATE/UGC/ICAR, etc. If yes, indicate the name of the examination, year and grade : No Professional/employment record (if any, in chronological order) : No Provide details of demonstrable research experience (e.g. publications, dissertations, patents, etc.) Title of Ph.D. thesis and name of Supervisor Title of Ph.D. thesis : Name of Supervisor : Details of break in career after highest qualification, if any (gap period in years with reasons for break) : No Name three (3) institutions and scientists in the country who are working in the proposed area of research

11.

12. 13. 14.

15.

16.

17.

Are you getting or availed fellowship/scholarship through any other scheme. If yes, please provide details : No Any other relevant information

18.

SECTION + # DET I)S O- THE ".D /"O&ECT

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Title of the Project Broad subject area (as given in Subject Code) Area of specialization Total cost of the project Summary of the proposal (not exceeding 500 words) Objectives National and international status Methodology Work plan Expected deliverables/outcome Significance of the expected outcome with respect to the state-of-the-art in the field Name, address of the institution and bio-data of the scientist-mentor (including last 5 years publications in cited journals) with whom the proposed R&D study will be executed. Facilities in terms of laboratory, equipment, etc. likely to be made available to the candidate by the host institution for pursuing the above studies Details of financial requirements (with justification) for the duration of the project (3 years) and year-wise phasing Head Research fellowship Consumables Travel (within India) Contingencies Equipments (generic name) Overhead charges GRAND TOTAL 1st Year 2nd Year 3rd Year Total : Physical Sciences : Thin Film Physics

13. 14.

S.No. 1. 2. 3. 4. 5. 6. 7.

15. 16.

Justification for the budgetary requirement item wise based on the scientific needs of the project Details of research funding received or applied for (mention reference no., title, duration, cost, funding agency and brief achievements)

Incomplete application in any respect lia0le to 0e re1ected