Nr. Railway Station, Kim (East), Dhanvantary College Road, Dist: Surat-394110, Gujarat, India.

Visit us at: www.sdcde.org Email: sdcdeprincipal@gmail.com

APPLICATION FORM

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Post Applied for : ______________________________________________ Duly Signed
Recent
Department : ______________________________________________ Passport Size
Photograph
Specialization : _______________________________________________

1. (i) Full Name (In Block Letters) :

_____________________________________________________________________________
(As in HSC Mark sheet)
(ii) Fathers / Husband Name: ______________________________________________________________

2. Date of Birth : __________________ Age : ((As on date) Completed Years) __________________

3. Gender : Male / Female Marital Status : Married / Unmarried
4. Correspondence Address : _____________________________________________________________
_________________________________________________________________________________
_________________________________________________________Pin _____________________

Phone No. : Office: ________________ Res : _________________ Mobile : ___________________

E-mail ID: (i) _____________________________ (ii) ___________________________________

5. Do you belong to (Please tick ) : SC / ST / OBC / Person With Disabilities (PWD)/ ExServiceman /
Dependent of Defense personnel killed/Disabled in war action:
____________________________________________________
6. Post held at present:
Nature of the Post
Post held at Date of Name & Address of Employers
(Temporary /
present * Appointment with present salary
Probation/ Permanent)

*Copy of appointment order is attached: Yes / No

Type of organization (Government / Semi Government / Grant in Aid) _____________________

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7. Educational Qualifications: (From Undergraduate Onwards)

Class/ *Equivalent
Sr. Examination Name of the Year of No. of
Percentage Percentage in
No. Passed University Passing attempts
/ CGPA case of CGPA

* Proof of Conversion from CGPA to percentage is a must.

8. Prizes, Awards, etc.:_______________________________________________________________

_______________________________________________________________________________________

9. Professional / Educational Experience: (From Present Post to Back)

Length of Service
Sr. Employers Post Pay Scale Total (date) Nature of work
No. Name held Emolument
From To

10. (A) Total Experience : _______________ Year(s) _______________ Month(s)

(i) Teaching Under graduate : _______________ Year(s) _______________ Month(s)
Post graduate : _______________ Year(s) _______________ Month(s)
(ii) Research : _______________ Year(s) _______________ Month(s)
(iii) Industrial : _______________ Year(s) _______________ Month(s)
Any Break in Service : Yes / No
If Yes state the period of break : _______________ Year(s) _______________ Month(s)
& reason_______________________________________________________________________

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(B) Research Activities: (Excluding M.Tech. Dissertation & Ph.D. Work)

Sr. Degree Registered / Duration (Date) University / Funds

Sponsoring Present Status
No. Project under taken Sanctions
From To Authority

(C)Publication:
National Journal
Sr. Month /
Name of Journal Volume No. Title (In Short)
No. Year

International Journal
Sr. Volume Month /
Name of Journal Venue Title
No. No. Year

Conference / Seminar
Sr. Name of Conference/ Month /
Venue Title
No. Seminar Year
International Conference/
Seminar

National Conference/
Seminar

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(D) Other Activities:
(i) Number of Expert Lectures Delivered: ________________________________________________
(ii) Number of Summer / Winter schools / Training Programmes: ____________________Organized
(iii) Number of Seminar / Conference / Workshop / Networking: ___________Programme Organized

Administrative & Community Services:(e.g. Dean/ Vice-Principal/ Principal/ Hostel Warden/ HOD/ Dept. In
charge/Chairman - Board of Studies/ Self Development Programmes for community Services)

Sr. Name of Responsibility Shared/Service

Name of Assignment Duration
No. Offered

11. Member of Technical Societies : _____________________________________________________

__________________________________________________________________________________

12. Please give details of two References:

(i) Name: _________________________ (ii) Name: ____________________________________

Designation: ____________________ Designation: ________________________________

Full Address: ____________________ Full Address: ________________________________

_______________________________ ________________________________________

Contact No. & Fax ________________ Contact No. & Fax ___________________________

E-mail: _________________________ E-mail: ______________________________________

13. Extra Curricular Activities / Hobbies :______________________________________________________

___________________________________________________________________________________

14. Any other Relevant Information : ______________________________________________________

DECLARATION
I declare that the statements made in this application are true to the best of my knowledge and belief.

I understand that misleading or wrong information supplied may lead to immediately rejection of
application/ appointment if found subsequently.

Date: _____________________

Place: (Signature of Applicant)

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