(To be submitted to the Research Department)

1. Applicant Details

• Name of Applicant: _______________________________
• Designation: _______________________________
• (Faculty/ Students):________________
• Department: _______________________________
• Institution/College: _______________________________
• Employee/Staff ID: _______________________________
• Mobile Number: _______________________________
• Email ID: _______________________________

2. Publication Details

• Title of the Article: ___________________________________________
• Authors: ___________________________________________
• Journal Name: ___________________________________________
• ISSN/Indexing: ___________________________________________
• Date of Acceptance: ______________________
• Date of Publication: ______________________
• Publisher Name: __________________________
• Type of Journal: ☐ National ☐ International
• Open Access: ☐ Yes ☐ No
• Scopus/Web of Science/ Pub-med/ UGC Listed: ☐ Yes ☐ No
• Series of Journal: (Q1/Q2/Q3)

3. Reimbursement Details

• Total Amount Paid for Publication: ₹ ____________
• Currency (if other than INR): ____________
• Payment Date: ______________________
• Mode of Payment: ☐ Online Transfer ☐ Credit/Debit Card ☐ Other: ________

4. Bank Account Details for Reimbursement

• Name of Account Holder: _______________________________
• Bank Name: _______________________________
• Branch: _______________________________
• Account Number: _______________________________
• IFSC Code: _______________________________

5. Attachments Checklist (Please tick)
   ☐ Copy of published article
   ☐ Payment receipt/proof of transaction
   ☐ Journal acceptance letter
   ☐ Copy of journal indexing proof -SJR (SCOPUS/WOS/PUBMED/UGC).
   ☐ Any other relevant document: _____________________

Declaration by the Applicant
I hereby declare that the details provided above are true to the best of my knowledge and the expenses claimed are not reimbursed from any other source.

Signature of Applicant: _____________________
Date: _____________________

Head of Department Signature:  _____________________

 

For Office Use Only

• Verified by Research: _____________________
• Remark: _________ _
• Amount Sanctioned: ₹ ____________
• Sanctioned By: _____________________
• Date: _____________________

 

RESEARCH HEAD                           PRINCIPAL                              CHIEF OPERATING OFFICER