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Application Form (ST)

Candidates must enter the same name in the same configuration as they are entering while applying to GATE-2014. (For example, if the candidates is entering Ravi Kumar Singh in the ONLINE GATE application, he must enter Ravi Kumar Singh (exactly same spelling) while applying to IndianOil ONLINE. He must not enter R K Singh or Ravi K Singh

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Murali Krishnan Nair
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86 views

Application Form (ST)

Candidates must enter the same name in the same configuration as they are entering while applying to GATE-2014. (For example, if the candidates is entering Ravi Kumar Singh in the ONLINE GATE application, he must enter Ravi Kumar Singh (exactly same spelling) while applying to IndianOil ONLINE. He must not enter R K Singh or Ravi K Singh

Uploaded by

Murali Krishnan Nair
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 8

Central Institute of Plastics Engineering & Technology

Department of Chemicals & Petrochemicals


Ministry of Chemicals & Fertilizers, Govt. of India

Application Form for the post of ..

Signed
Passport
size colour
photo

1.

Full Name (including Surname)


(in block letters)

________________________________________________

2.

(i). Date of Birth


(ii). Place of Upbringing
(iii). Blood Group

:
:
:

3.

Whether Physically Challenged:


(i) Yes / No.
(ii) If Yes whether OH/HH/VH
(Orthopedically/Hearing/Visually)

________________________________________________

(iii) State % of Disability


:
[Please attach latest disability certificate not earlier than three years from date of this application)
4.

Sex

: Male / Female (Strike off whichever is not relevant)

5.

Marital Status

: Married / Unmarried / Divorced / Widow/er (Strike off


whichever is not relevant)

6.

(a). Nationality

(b). Religion

(c). Mother Tongue

(a) Mother's Name and Address

_______________________________________________

7.

______________________________________________
(b) Father's Name and Address

_______________________________________________
________________________________________________

(c )

Page 1

S.No.

Relationship

1.

Father

2.

Mother

3.

Spouse

(d) Name of Spouse

Name of the Firm


employed

Place of
employment

Gross Annual
Income (in Rs)

_______________________________________________

(e) No. of Children / their age / Study /


Employment Details
_______________________________________________

8.

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.

9.

Have you ever faced any Vigilance Enquiry or enquiry by anti-corruption bureau/Central Bureau
of Investigation or any other Investigative Organization: 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)

_______________________________________________________________________________________

Page 2

10.

(a)
Postal Address for correspondence

_______________________________________________

(any change of address should be

_______________________________________________

communicated at once to the Institute)

_______________________________________________
Pin Code _______________________________________

(b)
Your Personal Phone/Mobile/E-mail details
(Res.) 1). _________________________

2).___________________________

(Mob.) 1). _________________________ 2).____________________________


Your Nearest Relatives Mobile No.

1). ________________________
2)._________________________

Your Personal E-mail :


(c)
Permanent Address
(Mention Street, Area, District and
State you belong to)

_______________________________________________
_______________________________________________
_______________________________________________

(d)
Postal Address of the Present Employer _______________________________________________
_______________________________________________
________________________________________________
Pin Code _______________________________________
Telephone Nos.
(Office) _______________________ (Mobile of Employer) ______________________________
E-mail:
Present Employers Website:_________________________________

11.

Academic Qualifications: (1)

Please attach Xerox copies of certificates & mark sheets


Page 3

including Date of Birth.


Give particulars in a chronological order starting with High School Certificate to M.Tech. / Ph.D*

S.No.

Name of Course /
Degree / University /
Board

Subject/
Specialization

Whether
Full Time /
Part time /
Correspond
ence Course

% of
Marks

Class /
Division

Period of Study
From - To

Whether course
passed /
Not passed /
Year of Passing

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

12.

S.N.

Professional /Teaching / Research Employment details: (Give particulars in descending


chronological order starting with the present post).
Employer

Post held

Pay Scale & Gross


Salary

Page 4

Place / State
of
Employment

Period of Employment
(Month/Year)
From

To

NB: If Self Employed, please indicate average monthly income.

13. Title of your M.Tech and Ph.D. Thesis ( whichever is applicable ) with name and complete address of
Guide. (Enclose abstract of thesis)
Degree

Title of Thesis

Guide name and


address

University

(1). M.Tech

(2). Ph.D.

14.

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

If you claim Research Experience furnish details on :


Sponsored Research Projects Completed / In progress.
Sponsored Consultancy Projects Completed /In progress.
No. of M.Tech. thesis supervised / co-supervised .
No. of Ph.D. thesis supervised / co-supervised .
No. of books published .
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.)]
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.)}
Feasibility project prepared (details including agency for which prepared).
Patents/Technology transfer if any:
Page 5

16.

If you claim Teaching Experience furnish details on:


Teaching at University level:
Total No. of Years
Attach list of courses taught at under graduate / post graduate level.
Short-term Courses (Conducted/Attached) (attach list)
Any other teaching - No of years:
Specialized courses/laboratories developed
Innovations in teaching:
Syllabus developed.

17.

If you claim experience on the applied side: Industrial or else with expertise relevant to job applied,
please give a brief account of duties performed / being performed by you

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

18.

Current Membership of Professional Bodies and Awards / Prize won / Scholarships received(if any) :
a) National Level
International Level
1. ________________________
____________________________
2. ________________________
b) National Awards
(Indicate Year)
1. _______________________
2. ________________________

19.

____________________________
International Awards
____________________________
____________________________

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

20.
(1)
(2)
(3)

Knowledge of foreign languages:

21.

Overseas assignment / training:

22.

References
Page 6

Responsible persons, not related to the applicant but closely acquainted with applicants academic and
professional work.

Name and Designation

23.

Address
Phone:
Email:

Fax:

Phone:
Email:

Fax:

Last drawn pay details (Salary Certificate to be attached)


Basic Pay

Rs.

D.A./I.D.A.

Rs.

H.R.A.

Rs.

CCA

Rs.

Other Allowances

Rs.

Total Gross Salary

Rs.

Scale of Pay:

24.

Notice period / No. of days likely to be availed for relieve from parent organization on selection:

25.

a). Details of relatives working at CIPET, if any :

b). Any other information you may like to furnish to CIPET:

26.

Social / Political / Religious Affiliations of the Candidate if any, Mention the name and clear details
about the affiliation :

27. Declaration
Page 7

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. In case of any misrepresentation,
I understand that employment if any gained, is liable for termination.

Place :

Signature

Date :

28. Annexures (to be enclosed with application form) :


a). Proof for date of birth (SSLC marksheet or Birth Certificate or Pan Card etc)
b). Certified copies of educational certificates with mark sheets
c). Certified copies of experience certificates
d). Disability certificate, if Physically challenged
e). Community certificate
f). Proof of Identity (Pan card or Voter ID card or Driving licence etc.)
g). One passport size photograph affixed in first page
Please Note : 1). All entries in the application form shall be neatly typed.
2). The name column shall be typed in bold capitals.
3). E-mail id & Mobile no. shall be compulsorily provided

Page 8

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