Application Form for GUEST FACULTY

Application Form For GUEST FACULTY

1. Full Name (including Surname) ______

(in block letters)

2. Date / Place of Birth/Blood Group ______

3. Community i.e. SC/ST/OBC/GEN. ______

4. Whether Physically Challenged:

(i) Yes / No. ______

(ii) If Yes whether OH/HH/VH

(Orthopedically/Hearing/Visually) ______

5. Sex Male / Female (Strike off whatever is not relevant)

6. Marital Status Married / Unmarried / Divorced / Widow/er (Strike off

Whichever is not relevant)

7. (a). Nationality ______

(b). Religion ------

(b). Mother Tongue ------

8. (a) Mother's Name and Address ______

------

(b) Father's Name and Address ______

------

(a)

Postal Address for correspondence ______

(any change of address should be ______

communicated at once to the Institute) ______

Pin Code ______

Telephone Nos.

Office ______

Res. ______

Mob. ______

Email: ______--______

(b)

Permanent Address ______

(Mention Tehsil, District and State ______

you belong to) ______

10. Were you at any time declared ______

medically unfit; asked to submit

your resignation; discharged or ______

dismissed from Govt./Semi-Govt./

Autonomous Body or Private Service ? ______

If yes, give details In a separate sheet.

11. Have you ever –faced any Vigilance Enquiry or enquiry by anti-corruption bureau/Central Bureau of Investigation or any other Investigative Organization or convicted in any court of law : Yes / No

If Yes: Please indicate in brief, the details of the Vigilance Enquiry and outcome thereof (If exonerated, a copy of the order passed by the competent authority may be furnished)

______

12. Academic Qualifications: (1) Please attach Xerox copies of certificates & mark sheets

including Date of Birth.

(a) Give particulars in a chronological order starting with High School

Certificate to Ph.D*

Sl. No. / Degree/ Certificate / Regular/Part time / Subject/
Specialization
/ Division/ Grade / % of Marks / Year / University / Board

* In case of M.Tech./ Ph.D the title of thesis to be mentioned along with copies of synopsis of thesis to be attached.

13. Academic & Research Employment details: (Give particulars in descending chronological order starting with the present post).

Sl.No / Employer / Post held / Pay Scale / Basic Pay / Period of Employment
(Month/Year)
From / To

NB: If Self Employed please indicate average monthly income.

14. Title of your Ph.D. Thesis with name and complete address of Guide. (Enclose abstract of thesis)

Degree / Title of Thesis / Guide name and address / University
Ph.D.

15. Area of specialization (to be filled in on the basis of Academic Qualification and experience relevant to the post applied):

Main Field / Specialization / Super-Specialization

16. If you claim Research Experience furnish details on :

i) Sponsored Research Projects – Completed / In progress.

ii) Sponsored Consultancy Projects – Completed /In progress.

iii) No. of M.Tech. thesis supervised / co-supervised

iv) No. of Ph.D. thesis supervised / co-supervised

v) No. of books published

vi) No. of research paper / review paper publications. [Enclose list of publications in Journals with impact factor (mention co-authors(s), Title, Journals, Months & Year, Page Nos.)]

vii) No. of research papers presented in International Conferences {(Enclose list of papers presented in Conferences (mention co-authors(s), Title, Conference, Month & Year, Page Nos.)}

viii) Feasibility project prepared (details including agency for which prepared).

ix) Patents/Technology transfer if any:

17. If you claim Teaching Experience furnish details on:

(a) Teaching at University level:

(i) Total No. of years

(ii) Attach list of courses taught at under graduate / post graduate level.

(iii) Short-term Courses (Conducted/Attached) (attach list)

(b) Any other teaching - No of years:

(d) Innovations in teaching:

(e) laboratory developed

(f) Syllabus developed.

18. If you claim experience in Admn. (Principal / Director / HOD / Controller of Examinations / Registrar etc.) with expertise relevant to job applied, please give a brief account of duties performed by you

______

19. Current Membership of Professional Bodies and Awards / Prize won / Scholarships received (if any)

a) National Level International Level

1. ______

2. ______

b) National Awards International Awards

(Indicate Year)

1. ______

2. ______

20.

(i) Specialized area you would like to strengthen on joining CIPET. (Annexure – I) (A brief write up may be given).

(ii) Why you should be considered for the positions applied. (Annexure – II) (A brief write up may be given).

21. Knowledge of foreign languages:

(1)

(2)

(3)

22. Overseas assignment / training:

23. No. of days likely to be availed to join on selection:

24. Any other information you may like to furnish to CIPET:

N. B. : (Use separate sheets wherever necessary while filling application form above)

25. Copies of documents enclosed:

(i)

(ii)

(iii)

(iv)

(v)

(vi)

Declaration

I Declare that the Entries made in the Columns of this proforma are correct and true to the best of my knowledge and nothing has been either concealed or misrepresented by me

Place : Signature

Date :