ROURKELA
APPLICATION FORM FOR REGULAR FACULTY POSITION
(Advt No. ____________, dated 26.02.2014.)
Post applied for Discipline .. College Category (UR/ SC/ ST/ SEBC/ OPH) .. Draft No. ________ Date ________ Amount______
(enclose the caste certificate/ Medical certificate for claim of reservation)
1. 2. 3. 4. 5. 6. 7. 8.
Name in Full Date of Birth (DD/MM/YY) Nationality Category (General/ SC/ST) Sex (Male/ Female) Marital Status (Married / Unmarried) Fathers Name/ Husbands Name Address for Correspondence
9. 10.
: :
Sl No
Exam passed
Subjects
Specialization
% of Marks/ CGPA*
Division
Rank/ Position
If any
1 2 3 * Please specify the percentage of marks upto two decimal place * In case of CGPA / CPI, please give marks in percentage along with the conversion formula
11.
Science & Humanities / Engineering Discipline : Field of Specialization : Length of Experience : : Period From To Training Area
12.
13.
Employment Records
Period of service From To
:
Designation Scale Pay of Work Description Reason of leaving Total period of employment
14.
: Year
: Year
18. Sl
19.
International National State Professional bodies Any other 20. Publications : No. Books Book Chapter (s) Monograph Title & Year
Academic Fellowship (i)_________________________ (ii)_________________________ Professional Body Membership (i)_________________________ (ii)_________________________ 22. Sl. No. 1 2 Other Academic Activities (Curricular/ co-curricula/ Examination/ Hostel/ Sports/ NSS/ NCC/ Scouts etc) : Name of the activities Date of activities held Remarks
Minimum joining time require (if selected) : Have you been interviewed by any University during past year ? give detail Name of the post & discipline Date of interview Result/ remarks
26.
27.
Declaration : I declare that the foregoing information is correct to the best of my knowledge and belief and
nothing has been concealed / distorted. If any time, I am found to have concealed / distorted any material information, my appointment shall be liable to termination without notice. I will, if and when required, take up duty in the discharge of Government assignment anywhere in India.
Place : Date :
Signature of Candidate