Central Institute of Plastics Engineering & Technology

Signed
Passport
size colour
photo

Application Form
1.

Post Applied to

________________________________________________

2.

Full Name (including Surname)

(in block letters)

________________________________________________

3.

Date of Birth / Place of Upbringing / Blood Group_________________________________________

4.

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

5.

________________________________________________

Whether Physically Challenged:

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

________________________________________________

_________________________________________________

6.

Sex

Male / Female (Strike off whatever is not relevant)

7.

Marital Status

8.

(a). Nationality /Religion

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

whichever is not relevant)
___________________________________________

(b). Mother Tongue

----------------------------------------------------------------------

(a)
(b)
(c)
(d)

_______________________________________________
_______________________________________________
_______________________________________________

9.

Mother's Name and Address

Father's Name and Address
Name of Spouse
If Spouse employed, Name of firm
& Place of Employment
(e) No. of Children / their age / Study /
Employment Details

_______________________________________________
_______________________________________________

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10.

(a)
Postal Address for correspondence

_______________________________________________

(any change of address should be

_______________________________________________

communicated at once to the Institute)

_______________________________________________
Pin Code _______________________________________
E-mail :

(b)
Postal Address of the Present Employer _______________________________________________
_______________________________________________
________________________________________________
Pin Code _______________________________________
Telephone Nos.
(Office) __________________________________
E.mail:

Website _______________________________

(c) (Res. Landline) 1). _________________________

(Mobile.)

1). _________________________
Your Nearest Relatives Mobile No.

2).___________________________
2).____________________________
1). ________________________
2)._________________________

(d)
Permanent Address
(Mention Tehsil, District and State
you belong to)

_______________________________________________
_______________________________________________
_______________________________________________

11.

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.

12.

Have you ever faced any Vigilance Enquiry or enquiry by anti-corruption bureau/Central Bureau
of Investigation or any other Investigative Organization: Yes / No
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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)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

13.

Academic Qualifications: (1)

Please attach Xerox copies of certificates & mark sheets

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 /
Correspondence
Course

% of Marks /
Class
obtained

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.

14.

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

chronological order starting with the present post).

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Employer

S.N.

Post held

Pay Scale & Gross

Salary

Place / State
of
Employment

Period of Employment
(Month/Year)
From

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

15. 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

(1). M.Tech

(2). Ph.D.

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University

To

16.

17.

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:

18.

19.

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:
laboratory developed
Syllabus developed.

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

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

20.

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

____________________________

2. ________________________
b) National Awards
(Indicate Year)
1. _______________________

____________________________
International Awards

2. ________________________

____________________________
____________________________

21.

Outline few project proposals that you would like to submit to various funding agency on joining
CIPET. (Annexure I) (A brief write up may be given).
Specialized area you would like to strengthen on joining CIPET. (Annexure II) (A brief write up
may be given).
Why you should be considered for the positions applied. (Annexure III) (A brief write up may be
given).

22.
(1)
(2)
(3)

Knowledge of foreign languages:

23.

Overseas assignment / training:

24.

Reference

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

Name and Designation

25.

Address
Phone:
Email:

Fax:

Phone:
Email:

Fax:

Last drawn pay details (Salary Certificate to be attached)

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Basic Pay

Rs.

Scale of Pay:

D.A./I.D.A.

Rs.

H.R.A.

Rs.

In case of Govt. / Quazi-govt. firms

State whether scale of pay above is
Pre-revised / Revised scale of Pay :

CCA

Rs.

Other Allowances

Rs.

Total Gross Salary

Rs.

26.

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

27.

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

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

28.

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

29. For Re-appointment (applicable for Ex-Employees).

(a)
Employment details at the time of Resignation from CIPET.
i
)
Date of Resignation
i
i
Designation & Grade held
)
i
i
Department & Division
i
)
i
v
Last scale of pay drawn at
)
CIPET.

(b)
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i)
ii
)
ii
i)
i
v
)
v
)

Employment details at the time of joining CIPET.

Date of joining of CIPET
Designation & Grade to
which appointed.
Department & Division
Scale of pay drawn during
initial posting at CIPET.
PF No. at CIPET.

N. B. :

(Use separate sheets wherever necessary while filling application form above)
30. 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. In case of any misrepresentation,
I understand that employment if any gained, is liable for termination.

Place :

Signature

Date :

Forwarding of Application through proper channel: (To be filled in by the forwarding authority).
(Applicable for Candidates from Central/State Govt./PSU/Autonomous/Quazi-Govt. only)
Date: ________
Forwarded to the Chief Manager (P&A), Central Institute of Plastics Engineering & Technology (CIPET),
Head Office, Guindy, Chennai.
The applicant has been working in this office / organization / institute /
university as ________________________________ since and is still in service. We have No Objection to
his/her candidature being considered for the post he / she is applying.
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Place:
Signature ________________
Designation ______________
(With Seal)

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