भारतीय प्रोद्योगिकी संस्थान भुवनेश्वर 
INDIAN INSTITUTE OF TECHNOLOGY BHUBANESWAR
 शैक्षणीक अनुभाग /Academic Section 	

APPLICATION FOR TEMPORARY WITHDRAWAL / NON-RESIDENT
       (For Research Scholar only, as per Ph.D. Regulation Para 7.2.1)

NAME   	__________________ROLL NO   			 Dept./Centre  		Category ______________________	Hall  		  Date of joining  	  Date of Registration Seminar  			   Proposed date of leaving  		  Period of stay completed ________________year (s)
 	months  	days.

Name of Supervisor (S)	 : (1)    	_________

: (2)  		________ Reason for withdrawal: __________________________________________________ 		____ Course work assigned  		____Cr. Completed  		 Cr.
H.S.S. Subject /Language course 	: Completed I Incompleted

Demand position:
(a)   Whether Mess dues are cleared upto date :

Yes/No    	_____

(b)  Whether Institute dues are. cleared upto date : Yes/No                                             _____ (c)  Whether  Library Books I Cards are returned :    Yes/No                                             _____ (d)  Whether Departmental dues are cleared:              Yes/No                                           _____  
Full address for correspondence: ___________________________________________________

_---------------------------------------------------------------------------------------------------------------------------------------

e-maill   ID:-----------------------------------------------------------

Telephone number:_________________________________________

Signature of the Research Scholar

P.T.O

Countersigned and verified by

Supervisor (s)       Chief Warden/Warden 	Librarian 	HOD/HOC/HOS

RECOMMENDED

The scholar may be permitted to submit thesis from outside as : 
(1) He/She completed the prescribed course work
(2)  He/She has also fulfilled the minimum residential requirement
(3) Adequate research facilities are available to carry out the research work in his/her parent
     Organization/Institution/Place of working 

(4) He/She has registered on completion of Course Work and Seminar.

Signature of DAC Members: 1). 	,2)  	_

3)  	, 4)  	, 5)  		_

6)    	

Approved as recommended

Dean (PG&RP)