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CENTRAL INSTITUTE OF TECHNOLOGY, KOKRAJHAR

BTAD:: KOKRAJHAR :: ASSAM :: 783370

APPLICATION FOR FACULTY POSITION
Advertisement No.10/2014:Dated08/005/2014

1. Post applied for ........................................
2. Department/Subject: .......................................
3. Specialization (if any) ...........................................
4. Name in Full (In Block Letters) ....................................................
5. Fathers Name .................................................
6. Mothers Name ..................................................
7. Place and Date of Birth ... and ..
8. Postal Address for Correspondence: ..............................................
..
.PIN: .
Phone No: Mobile:
E-mail: ..
9. Permanent Address : ..........................................
...
. .....PIN: ...
Phone No: .. Mobile: ..
E-mail: ..
10. (a) Sex: M/F (b) Category (ST/SC/OBC) (c.) Nationality :..
(d) Religion: (e) Marital Status (Married/Unmarried/Divorced) ..
11. Academic Qualifications (Commencing with the High School or an equivalent examination).
Examination/
Degree
Board/Institute/
University
Year of
Passing
Marks (%
or
CGPA)
Division/
Class/
Grade
Subject(s)
Specialization
(if any)






Recent
passport size
photograph to
be affixed




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12. Title of Research Dissertations:

Degree Institute/University
Date of
submission
and award
Title of the work/Subject
Masters Level

Doctor Level


13. Is Ph. D. awarded as per UGC Regulation 2009? YES/NO
If YES, attach documentary proof.
14. Is NET/SLET/GATE qualified? YES/NO
If YES, attach documentary proof.
15. Achievements (like Ranks, Positions, Awards in Academic & other Activities)
Sl. No. Programme Rank/Position




NB: If space is not sufficient, information may be provided in separate sheet

16. Experience in Teaching/Professional/Research etc. (Give particulars in descending order starting with the
present post)
Post Held Name & Address
of Employer
Basic Pay Duration Nature of Duties/Work
From To




NB: If space is not sufficient, information may be provided in separate sheet.

17. Thesis Supervised
(a) Ph.D
Sl. No. Title of Thesis Supervised Completed (Year) Principal or Co-Supervisor




NB: If space is not sufficient, information may be provided in separate sheet





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(b) M.Tech/M.S. /M.Phil
Sl. No. Title of Thesis Supervised Completed (Year) Principal or Co-Supervisor




NB: If space is not sufficient, information may be provided in separate sheet.

18. List of Publications:

(a) International Journals

Sl. No. Name of the Journal Volume
No.
Month/Year/
Page No.
Authors Title of the paper




NB: If space is not sufficient, information may be provided in separate sheet

(b) National Journals
Sl. No. Name of the
Journal
Volume No. Month/Year/
Page No.
Authors Title of the paper




NB: If space is not sufficient, information may be provided in separate sheet.

19. Research Projects & Consultancies:

Sl. No. Title Agency Period Grant/Amount
mobilized (Rs.
Lakhs)



NB: If space is not sufficient, information may be provided in separate sheet

20. Papers Presented in Conferences, Seminars, Symposia, etc.
Sl. No. Title of the paper
presented
Title of
Conference/Seminar
Date
of the
event
Organized
by
Whether
International/National/
State/Regional/Univers
ity or College Level




NB: If space is not sufficient, information may be provided in separate sheet




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21. Participation in Conferences, Seminars, Workshops, Symposia, Training Programmes, etc.

Sl. No. Programme Duration Organized by



NB: If space is not sufficient, information may be provided in separate sheet.

22. Administrative Experiences: (e.g. Dean/Hostel Warden/HoD, etc)

Sl. No. Name of Assignment Duration Nature of Responsibility



NB: If space is not sufficient, information may be provided in separate sheet.

23. Extra-Curricular Activities: ..
.........
..
24. Any other Information :


..
25. Name and addresses of three persons (who are not related to the applicant) who are in a position to testify from
their personal knowledge as to the fitness of the applicant for the post applied for:

(a) Name: ....(b) Name: .
Designation: .. Designation: ...
Full Address: . Full Address: ..
.. ..
... ...
Contact No: . Contact No: .
E-mail: . E-mail: ..
(c) Name: .....
Designation: ...
Full Address: ..
...
...
Contact No: .
E-mail: .





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26. Details of Bank Draft:



27. I hereby declared that the entire information furnished in this form are true to the best
of my knowledge. If at any time, I am found to have declared any material/information or given any false details, my
appointment shall be liable to be summarily terminated without any notice or compensation.



Place:

Date: Signature of the Applicant

DD No. Date Amount Name of issuing Bank