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NATIONAL INSTITUTE OF TECHNOLOGY, AGARTALA

Special Recruitment Drive for PWD


Application Form for Recruitment of Faculty Position
(Please type or write using BLOCK LETTERS)

Post Applied

Name of the Post:

Recent
Passport size
photo

AGP:

Department
1. Name in Full

a) Father Name
Spouse Name
b) Gender

Male

c) Marital Status

Female

Married

d) Category

Trans
gender

Single
SC

ST

OBC

GEN

Percentage of Disability for PWD Candidate

VH

OH

2. Address:
(a) Permanent:
Address Line 1
Address Line 2
Address Line 3
City
Pin Code

State

(b) Address for Correspondence


Address Line 1
Address Line 2
Address Line 3
City
Pin Code

Mobile

State

HH

Telephone

Office

(with STD Code)

Res. No.

Email

3. Date of Birth:

4. Nationality
Day

Month

Year

4. Present Employment:
Designation
Organization
Date of Joining to the present post
Scale of Pay Rs.

AGP / GP:
(if applicable)

Current Basic Pay Rs.


Total Emoluments (per month) Rs.
5. Areas of specialization:

6. Academic Career Record starting with SSLC: (Attach photocopies)


Certificate/
Degree [UG &
PG]

Year

School/ College

Board/ University

Class/ Percentage/
Division
CGPA

Remarks/
Status

10th Level
10+2 Level

7. Academic - Doctoral Degree [Ph.D.] Details: (Attach photocopies)


Thesis Title

From
Date

To
Date

Institute /
University

8. Post Doctoral Work: (Attach photocopies)

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Guide / Mentor

Mode ( Full/
Part Time)

Final Viva
Voce Date

Award Date

Career

From
Date

To Date

Institute / Organization

Guide / Mentor

Field of Research
Work

9. National/State/Others -Test Scores/ Ranks (Attach photocopies)


Examination

10. Employment Details

Year

Branch / Area of Specialization

Score Rank

Percentile

(Particulars of your past employment in Chronological order starting with current employment -Attach

photocopies)

Employer

Position Held

Date of Date of
Joining Leaving

No. of
Months/
Years

Scale of Pay &


GP/AGP (If
Applicable)

Gross Pay

11. Total Experience (Number of Years and/or months)


Teaching Experience
Research Experience (Post-Ph.D.)
Industrial Experience

12. Teaching Experience (Number of Years and/or months)


Academic experience as
applicable (month / year) in the
posts indicated or equivalent

Assistant Professor or equivalent


Associate Professor or equivalent
Professor

13. Subjects Taught (Last 4 years)


Title of the Course taught

Year

U.G. / P.G.

14. Research guidance


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Approximate
No. of
students

Institution/University

Completed
Ph.D.

Ongoing
P.G.

Ph.D.

P.G.

15. a. Publication details - No. of Papers:


International

National

Journal Papers
Conference Publications
b. Provide best papers details (maximum 3)
Author

Title

Journal

Volume

Pages

Year

16.
Books / Chapters Published & E-learning
materials Developed (last 4 years)
17.
Patents
18. Sponsored Projects (Project handled as Principal Investigator in last 4 Years)
Funding Agency

Title of the Project

Project Cost

Duration

Current
Status

Remarks

Project
Duration

Project
Cost

19. Consultancy Project (in last 4 Years)


Funding Agency

Title of the Consultancy Work

20. Professional Training Received / Summer / Winter Schools attended


(Last 4 years - Attach photocopies)
Year

Nature of Training

Duration

Organization where
training was provided

21. Conferences / Seminars / Workshops attended (Last 4 years - Attach photocopies of the certificates)
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Year

Conferences / Seminars /Workshops


attended

22. Industrial Experience / Interaction (Attach photocopies):


Organization

Title of paper presented

Nature of work

Period

23. Continuing Education Programmes /Short Term Courses/Workshops/Seminars etc. organized (Last 4
years):
Title of Programme
Period
Funding Agency

24. Experience in Administrative Positions, Curriculum and Lab Development, Student Welfare, Professional
and Outreach Activities:

25. Awards and Recognitions (Attach photocopies):

26. Any other relevant information you may like to furnish:

27. Names and addresses of two Professional References: (Attach Testimonials of Them)
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Name

1.

2.

Position/
Designation
Address

Phone &
Fax
Mobile
E-mail
28. Please indicate how in your opinion you can contribute to NITAs growth. (Use a separate sheet, if
required)
(Limited to 250 words)

29. I hereby declare that the entries in this form are true to the best of my knowledge and belief. I understand that my
Candidature will be cancelled if any of the information is found to be false or incorrect. Further, if selected, I will abide
by the rules and regulations of the Institute and also the directions given to me from time to time.
Date

Place :
Signature of Applicant
List of Self Attested enclosures / certificates / testimonials (tick the appropriate ones)
1. Proof of Date of Birth
7. Conferences/Workshops attended and presented
2. Category certificate (SC/ST/OBC/PWD)
papers
3. Salary certificate / pay slip
8. Sponsored and consultancy projects
4. Academic records (SSLC marks card onwards up
9. Workshops / Conferences / Short Term Courses
to Ph.D.)
organized
5. Experience certificates
10. Publication and Patents details (list and reprints)
6. Training / Summer / Winter Schools attended
11. Awards and recognitions
12. Testimonials
___________________________________________________________________________________________
To be filled in by the forwarding authority (For Employed Persons only):

Date:

Forwarded to the DIRECTOR, NATIONAL INSTITUTE OF TECHNOLOGY, AGARTALA.


The applicant has been working in this Institute / organization as . since . and
is still in service. We have no objection to his/her candidature being considered for the post he/she is applying.
Place

: ..

Seal

Designation :

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Signature