KARNATAK UNIVERSITY
DHARWAD-580 003
KARNATAKA, INDIA
Dr. D. C. PAVATE MEMORIAL VISITING FELLOWSHIP TO
CAMBRIDGE UNIVERSITY- 2022-23
APPLICATION FOR FELLOWSHIP AT
 DEPARTMENT OF  ENGLISH 

(Selection All India Basis)
JUDGE BUSINESS SCHOOL  (For Karnataka Candidates Only)
DEPARTM ENT OF APPLIED MATHEM ATICS AND THEORETICAL PHYSICS /
DEPARTMENT OF MATERIAL SCIENCES AND METALLURGY / DEPARTMENT OF CHEMISTRY /
DEPARTMENT OF ZOOLOGY
(For Karnataka Candidates Only)
(Tick the Applicable  Department )
Coordinator
Office Use Only
Dr. D.C. Pavate Foundation
Vidya Soudha Building
First Floor
Karnatak  University Dharwad
  
Dharwad- 580 003

Karnataka
Reg No.:
Surname/ Family Name (BLOCK LETTERS)                                                     Nationality
Title: Mr/Mrs/Miss/Ms/Others                                                                Country of birth
First Name(s)
Country of permanent residence
Previous Surname (if changed)                                                               Gender :  Male/Female
Other (given) name(s)
1
 
Date of birth                                                                  Special needs (Please state briefly if you have any
disability or condition which requires special
facilities):
Month      Year
Day
        Address for correspondence
Telephones
: (Office)
(Residence)
Mobile no-
mail
E -
Permanent address (If different from above)
Education (only enter details  from graduation onwards):
Approximate dates :            Name of Institution                                    Subjects studied and
From-To                         (Please give town/country)                        Qualification
2
 
If you have previously studied at Cambridge University please give details :
Student Number                                                                  Previous name if changed since leaving
Referee details (NB: The first reference must be academic)
First Referee:                                                                  Second Referee :
Title : Dr/Mr/Mrs/Miss/Ms/Other                                     Title : Dr/Mr/Mrs/Miss/Ms/Other
Surname/Family name (BLOCK CAPITALS)                 Surname/Family name (BLOCK CAPITALS)
First Name                                                                            First Name
Occupation                                                                          Occupation
Relationship to applicant                                                      Relationship to applicant
3

Address                                                                                   Address  
Mobile no
                                     Mobile no                             
E-mail                                                                                  E-mail   
Confidential statements by referees (Please continue on separate sheet if necessary or enclose/forward the
statement separately as may be preferred by the Referee):
First Referee :
Second Referee :
4
 
Work experience (Give details of work experience, training, employment and achievements to date):
Approximate dates :                                Employer's name
From-To                                                and Address                                     Name of Employment
Name of your present employer
Length of time with current employer  Years Months
Current job title
5
 
Explain your current job and responsibilities
Have you discussed your application with your employer? Yes/No
.
Are they prepared to pay all or part of your costs ? Yes/No

Will provide you with facilities to undertake an in-company project? Yes/No
.
Name and position of relevant contact within your organization.
Personal statement (Describe your proposed course or specific project and its likely impact on your future
occupation. Please give reason: why do you consider your project and yourself suitable for Fellowship/
Scholarship and reasons for pursuing it at Cambridge. 

6
 
(Enclose additional sheet if need be)

Please list and specify materials enclosed, including papers/ articles published
Karnataka Candidates: (Applicable/ Not Applicable)
If applicable, please furnish documentary particulars.
Note:
Any Statements in this form which prove to be untrue or purposely misleading will cause the application to
be cancelled
Declaration:
I confirm to the best of my knowledge, the information given in this form is correct and complete.
Applicant’s Signature _____________________ Date: _________________

Certificate of Employment/Head of Institution
Certified that Mr/Ms/Dr. __________________________________applicant herein the employee of the Government of 
____________________/University of ________________/ _____________________/ Institution. The employee shall
 be given  study leave in the event his/her selection and award of the Dr. D.C. Pavate Memorial Visiting Fellowship to
English Department/ Department of Applied Mathematics and Theoretical Physics/ Department of Material Sciences and Metallurgy,
 Department of Chemistry/ Department of Zoology, Cambridge, U.K. 

Return the application form by10-12-2021
Employer/ Head of Institution/ Govt. Dept.
7