AAA05177674

Birla Institute of Technology & Science,Pilani,Rajasthan

Work Integrated Learning Programmes Division

Application for Admission to M.Tech. Artificial Intelligence & Machine Learning for 2024-25

For Office use only

ID No: 2024AA05______ Date of Receipt:_________________

Remarks,if any:________________________________________

Dean Vice-Chancellor

Note:Please read the instructions carefully before filling in this application form.

SECTION 1:PERSONAL INFORMATION & EDUCATIONAL BACKGROUND

1.Name: PRAJWAL S
2.Gender: Male
3.Date of Birth: 10 Jun 1999
4.Father's Name: Sri Harsha HS
5.Mother's Name: Vanishree AS
6.Email: prajwal123.ai@gmail.com
7.Mobile/Phone: +91 70199 94661/+91 70199 94661
8.Nationality: Indian
9.Do you belong to Scheduled Caste or Scheduled Tribe?[Y/N] ___
10.Address for Correspondence: 999B, B-G002, 1st Floor, Ideal
Sky View
1s Main Road, Ideal Homes
Township
RR Nagar
Bengaluru,Karnataka,India

11.Educational details from School Leaving Certificate onwards in chronological order:

Qualification Name of Year of Total

Subject/Branch Board/University Duration(Years) Division
Level Diploma/Degree completion Marks/CGPA

Visvesvaraya
Graduation or MECHANICAL Technological
B.E. 4 year 2021 8.15 1st division
equivalent ENGINEERING University
(VTU)

SCIENCES
10+2 level, 10+2 Level Karnataka
(PHY. CHEM. 1 year 2017 87.83 1st division
Diploma 3 yr (Intermediate) State PU Board
MATH.)

10th level,
10th Grade 10th
matriculation or ICSE 1 year 2015 88.60 1st division
(Matriculation) MATRICULATION
equivalent

*As Calculated for declaring result and award of Division by your Board / university.If marks are not awarded,give Cumulative Grade Point Average Or
its equivalent.Explain below the basis on which your B. SC. / B.E. M. SC. / M. C.A. (Or equivalent)final percentage is Calculated (Cleary explain gaps, if
any in a separate Sheet.)

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12.Level at which you have studied Mathematics: Graduate Studies (Engg. And Science)

13.Are you currently enrolled for degree or diploma in any University/Institution: (Y/N) N

If Yes,give details specifying the University Institution name,programme name,duration,date of joining the programme and likely date of completion of the same.

14.Have you ever been a student of BITS,Pilani.(Yes/No):if yes,please write name of the degree and your ID No.:

15.Exam Centre Choice: Bangalore-South (Karnataka)

The evaluation methodology requires admitted students to appear in person at any of the designated exam centres located in Ahmedabad / Bangalore-Central /
Bangalore-East / Bangalore-North / Bangalore-South / Bhubaneswar / Chandigarh / Chennai-Central / Chennai-North / Chennai-South / Coimbatore /
Delhi / Dubai / Goa / Gurugram / Guwahati / Hyderabad / Indore / International / Jaipur / Jamshedpur / Kochi / Kolkata / Lucknow / Mumbai / Nagpur /
Navi Mumbai / Noida / Pilani / Pune / Pune-Pimpri Chinchwad / Secunderabad / Thiruvananthapuram / Vijayawada / Visakhapatnam twice during every
semester for taking their Mid-Semester and Comprehensive examinations. These examination sessions will be scheduled on Friday / Saturday / Sunday, and
students are responsible for making their own arrangements to visit any of the designated exam centres located in the above cities to take these exams. Please
specify your preferred Examination Centre for taking the Mid-Semester and Comprehensive examinations from the provided list.

Note: Due to operational reasons, the institute may request the students to appear at an Exam Centre location different from their preferred exam centre choice mentioned above. Additionally, students opting for the
Dubai exam centre will incur an extra exam centre fee, details of which will be provided at the time of admission.

16.Current Employment Status: Employed

17.Total Work Experience: 2 Years 9 Months 4 days

18.Work Experience in Current Organisation: 2 Years 9 Months 4 days

(as on applicable deadline to be counted only from the point of completing BE/MSc or equivalent))

19.Employment Details:Since the year of completing BE/MSc or equivalent,give brief employment details below in reverse chronological order.

Name of Employer Designation held Start Date End Date

Total Work Experience calculated after completing BE/MSc or

equivalent

Provide the dates of start end of the employment period.Clearly explain gaps,if any in a separate sheet.

20.Declaration by the Applicant

I have carefully read the details and instructions given in this application form and declare that all the information and statements made in various sections and
parts of this Application Form and enclosures are true to the best of my knowledge. I agree to the condition that if information or statements were found to be
wrong, my admission to BITS Pilani would automatically be cancelled. If admitted, I promise to abide by the Rules and Regulations in force or those that may
hereafter be made by the Institute, and I shall do nothing either inside or outside the Institute that will interfere with its orderly functioning and discipline. I pledge
to adhere to a regular study schedule and participate in examinations at the exam centre allocated by the Institute. As the person responsible for paying my
fees/dues, I will ensure timely fee payments to the institute throughout the programme. Furthermore, in all matters concerning the Institute and myself, I agree
that the decision of the BITS Pilani Vice-Chancellor shall be binding on me.

Place:________________________ Signature:_____________________
Date:________________________ Name:

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SECTION 2: EMPLOYER CONSENT FORM (This section must be duly filled in by all employed candidates)

This is to certify that our organisation acknowledges and consents to our employee for enrolling in a work-integrated learning programme with BITS
Pilani to upgrade his/her knowledge and learn new skills. We have no objection to this enrolment and permit the employee to pursue the
programme with the BITS Pilani Work Integrated Learning Programmes (WILP). We expect that this programme has the same rigour as that of a
full-time on-campus programme at BITS Pilani.

The programme will require the employee to leverage work-related problems for their academic projects and learning assignments, only in
compliance with the organisation’s policies and confidentiality requirements.

It will be our endeavour to provide a qualified senior professional from within the organisation, to act as a mentor for strengthening their
work-integrated learning. In case we are unable to provide a mentor from within the organisation, we have no objection to the selection of a mentor
from outside the organisation, as is agreeable to BITS Pilani.

Please note the following details, which are true to our knowledge:

Name of Employing Organization : Accenture

Name of Employee: PRAJWAL S

Employee ID Number:

Designation of Employee: Quality Engineering Analyst

Date of Joining the Organization: 28-10-2021 (Day/Month/Year)

Degree Programmme applied for: M.Tech. Artificial Intelligence & Machine Learning

Work Profile of the Employee : ___________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

Programme fees is being borne by: (Please select only one option)

• The organisation will not pay the fee and dues on behalf of the employee.

• The organisation will partly pay the fee and dues on behalf of the employee.
If yes, please mention the percentage of the fee being paid by the organisation. _________________________________________________

• The organisation will fully pay the fee and dues on behalf of the employee.

Name of the authorised signatory: ________________________________________________________________________________________

Designation of the authorised signatory: ____________________________________________________________________________________

Employee ID number of the authorised signatory: ____________________________________________________________________________

Complete address of the current office location of the signatory: _________________________________________________________________

________________________________________________________________________________________________________________________________

Signature & stamp of the authorised signatory: _______________________________________________

Date: _____________________

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SECTION 3: MENTOR CONSENT FORM

Role of the Mentor:

The basic role of the mentor will be to ensure that the student remains aligned with the academic objectives and the key academic milestones
while pursuing the programme. The mentor’s valuable guidance and professional expertise would also be leveraged to maximise work-integrated
learning and make the education experience highly relevant for the job role and pursuit of the long-term career goals of the student.

Qualifications for a Mentor:

The mentor chosen should be a senior professional with at least 5 years of relevant work experience, holding a B.E./ B.Tech./ M.Sc./ M.B.A./
M.B.B.S./ First Degree at BITS Pilani or its equivalent. If the mentor has less than 5 years of relevant work experience, then the minimum
educational qualification for the mentor should be M.E./ M.Tech./ M.S./ M.Phil./ Higher Degree of BITS Pilani or its equivalent is required.

Declaration from the Mentor:

Name of the applicant for whom I will be the mentor: _______________________________________________________

Programme that the applicant has applied for: _______________________________________________________

Full name of the mentor: _______________________________________________________

Designation of the mentor: _______________________________________________________

Highest educational qualification of the mentor, along with specialisation or branch: ________________________________________

Name of the university for the qualification mentioned above of the mentor: ________________________________________

Employer organisation of the mentor: ________________________________________

Total work experience in years and months of the mentor: _______ Years _______ Months

Total work experience in years and months of the mentor, in the current employer organisation: _______ Years _______ Months

Complete address of the mentor: __________________________________________________________________________________

________________________________________________________________________________________________________________________

Contact number of the mentor: ________________________________________

Email address of the mentor: ________________________________________

This is to provide an acknowledgement and acceptance of my role as a mentor for the applicant mentioned above enrolling with BITS Pilani’s Work
Integrated Learning Programme.

I agree to perform the following expected role as a mentor to the applicant if he/she enrols as a student for the above-mentioned programme:

1. Periodically monitor student’s study schedules and submission deadlines for the programme.
2. Provide guidance towards integrating learning from the programme with job role/long-term career goals, especially while the student pursues
their learning assignments and project work.
3. Monitor the student’s progress throughout the duration of the programme. If required by BITS Pilani, also try to be available to engage with the
faculty to collaboratively assess the student’s academic performance and recommend any learning improvement plan.
4. Emphasise the importance of self-study and self-learning throughout the programme to the student.

Signature of the mentor: _______________________________________

Date: __________________

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MANDATORY SUPPORTING DOCUMENTS

To complete the application submission process, candidates are required to submit copies of supporting documents through the Application
Centre.

Before uploading scanned copies of the mandatory supporting documents listed below, please ensure that they are complete in all respects, failing
which your application will be considered as incomplete and rejected. Please SELF ATTEST all academic mark-sheets and certificates using
your FULL SIGNATURE.

For certain documents such as marksheets where multiple pages may need to be uploaded, you may scan multiple pages into a single
pdf file and upload it. Alternatively, you may scan different pages as separate pdf files, then create a zip file of these pdf files and upload
it as a single zip file.

Documents to be uploaded

1. Application Form: This implies pages 1 & 2 of the downloaded pdf of the Application Form. Upload a single pdf file containing the two pages scanned together,
or a zip file that has separate pdf files for each page. Ensure that all additional information required therein has been filled legibly by hand, and photograph
and signature are present.
2. Photograph: Upload a soft copy of a professionally taken passport-sized photograph.
3. Employer Consent Form: Upload scanned copy of page 3 of the downloaded pdf of the Application Form. Ensure that all additional information required
therein has been filled legibly by hand, and signatures and company stamp are present.
4. Mentor Consent Form: Upload scanned copy of page 4 of the downloaded pdf of the Application. Ensure that all additional information required therein has
been filled legibly by hand, and signatures are present.
5. Degree Certificate(s): Upload scanned copy of BE/ B.Tech./ M.Sc./ MBA/ AMIE/ BITS Pilani B.S. or equivalent degree certificate that includes your name as it
is spelt. Upload all certificates together as a multi-page pdf, or a zip file. Self attest all the scanned pages.
6. Proof of Date of Birth: Upload a photocopy of your 10th Pass/ Matriculation/ Secondary School Leaving Certificate/ Marksheet clearly stating your date of birth.
7. Marksheet(s): Upload academic marksheets for all years/ semesters of all your degree/ diploma examinations. Upload all marksheets together as a multi-page
pdf, or a zip file. Self attest all the scanned pages.
8. Proof of Work Experience: For the current organisation, please upload a work experience certificate issued by the company HR. For previous organisations,
you may upload work experience certificates if available, or else submit the Appointment Letter along with the Relieving Letter. Upload all work experience
certificates as a multi-page pdf, or a zip file.
9. Company Brochure: Upload latest brochure giving detailed profile of the current employing organisation. In case the brochure is not available, upload copy of
the company profile as given on the company website.
10. Career Objective: Upload scanned copy of a write-up on your career objectives in applying to this programme.
11. Mentor Resume & Degree Certificate: Upload copy of detailed resume of your proposed Mentor along with an attested photocopy of his/ her highest degree
certificate. Upload a multi-page pdf, or a zip file.
12. Letter of Recommendation: If you are currently working for a University or an educational institution, upload a letter of recommendation from the head of the
institution, such as Vice Chancellor or Registrar of the University. Only those candidate who work with educational institutions are required to submit this
document.