Application Form
APPLICATION FORM FOR NON-FACULTY POSTS
xSjf’k{k.k in gsrq vkosnu çi=
Advertisement No./foKkiu la0%
Name of the post applied for / vkosfnr in dk uke%
Particulars of fee Remitted:
Amount_Rs.
Bank Draft No.
Date
Issuing Bank
’kqYd dk fooj.k
jkf'k ¼#-½____________ cSad Mªk¶V la[;k_______________ fnuakd____________ tkjhdrkZ cSad________________
1 Full Name (in Block Letters)
iwjk uke fgUnh esa
¼lkQ v{kjksa es½a
2 Fathers’s/Husband’s
Name
firk@ifr dk uke
________________________________________________
________________________________________________
________________________________________________
3 (a) Address for Correspondence i=kpkj ds fy;s irk
_______________________________________
_______________________________________
_______________________________________
Tel. No. (with STD Code) __________________
Fax No. (with STD Code) __________________
Mob. No. ________________________________
5
(a) Sex:
fyax %
(b) Category oxZ
v-fi-oxZ General lkekU;
Age on the last date given in this advertisement
SC v-tk-
bl foKkiu esa nh xbZ vfUre frfFk dks vk;q
Years o"kZ
Months ekg
Days fnu
VH oh-,p- HH ,p-,p- OH vks-,pPlease tick in the appropriate box mi;ZDq r ckDl esa lgh
7
oSokfgd fLFkfr % fookfgr@vfookfgr
(a)Nationality jk"Vªh;rk
(b)Religion /keZ
Applicant’s Signature:
vH;FkhZ dk gLrk{kj %
MKS
ST v-t-tk-
OBC
(c) if person with disabilities fodykax gksus dh n’kk esa
dk fu’kku yxkb;sA
6 Marital Status : Married/Unmarried
Ñi;k vius orZeku dh
ikliksVZ vkdkj dk
Loizekf.kr QksVks
fpidk;sa
(b) Permanent Address LFkk;h irk
______________________________________
______________________________________
______________________________________
Tel.No. (with STD Code) __________________________
Fax No. (with STD Code)__________________________
Mob. No ___________________________________
e-mail: ______________________________________
4 Date of Birth & Place tUe frfFk ,oa tUe LFkku
Affix recent
passport size
selfattested
photograph
1
Academic Qualification (Commencing with the High School or an equivalent examination).
8.
’kS{kf.kd ;ksX;rk ¼gkbZLdwy vFkok led{k ijh{kk ls çkjEHk djs½a s
Examination/
Degree
Subject/
Specialization
ijh{kk@mikf/k
fo"k;@ fo’ks"kKrk
Year
Division
Ok"kZ
Js.kh
% of
Marks/
Grade
vad %
xzsM
No. of
Attempts
Subjectwise.
fo"k;kuqlkj
ç;kl la[;k
University/
College/
Board
fo’ofo|ky;@
Distinctions/
Scholarship
fof’k"Vrk@
Nk=o`fÙk
dkWyt
s @cksMZ
Administrative/Teaching/Professional/Research Employment (Give particulars in descending order starting with the present post)
9.
iz'kklfud@'kSf{kd@O;olkf;d@vuqla/kku fu;kstu ¼orZeku in ls çkjEHk djds vojksgh Øe esa fooj.k ns½a
Employer
fu;ksDrk
*Status of
Institute/
University
laLFkk dh fLFkfr
i *Govt./Autonomous/Private.
10.
Period of Employment
Post Held
Pay Band
in
osrueku
fu;kstu dh vof/k
From/ ls
To/rd
AGP/GP
Nature of Duties/Work
dk;ksZ ds Lo#i
ljdkjh@v/kZljdkjh@Lok ;Ùk’kklh@futhA
Details of Experience in Educational Administration
Kindly provide the details of experience in about five hundred words on a separate sheet.
11.
Summary of experience/performance
dk;Z vuqHko@fu"iknu dk laf{kIr fooj.k
A
v
Teaching Experience
v/;kiu vuqHko
i
Under Graduate/Lukrd
ii
Post Graduate/ LukrdksRrj
iii
Total Teaching Experience/
iv
Administrative Experience (in years)
From
To
Total years & Months
ls
rd
dqy o"kZ vkSj eghus
dqy v/;kiu vuqHko
iz'kklfud vuqHko ¼o"kksaZ es½a
v
Short term/ Continuing Education/ Specialist Courses
conducted
vYikof/k@vuojr~ f’k{kk@fo’ks"kKrk ikB~;Øeksa dk vk;kstu
Note:- List of publications with details, reprints of papers and acceptance letters (in case of accepted papers) must be
enclosed izdkf'kr 'kks/k&i=ks dh lwph] mudh iqueqZfnzr izfr;k¡ ,oa Lohd`r ’kks/k&i=ks ds Lohd`r i= dh Nk;kizfr;k¡ layXu djsaA
Applicant’s Signature:
vH;FkhZ dk gLrk{kj %
MKS
2
B
y
Extra curricular activities- give details, if any, of proficiency acquired in games, sports and of participation in other extra
curricular or social activities such as NCC, Public Lectures, Debates, Social Service etc.
vU; xfrfof/k;ksa dk fooj.k& ;fn dksbZ gS] [ksydwn] ,u-lh-lh-] laokn çfr;ksfxrk vkSj lekt lsok vkfn
As a student fo|kFkhZ thou esa
After entering into service / ukSdjh esa vkus ds ckn
12
Training courses and conference/seminar/workshop papers
izf'k{k.k dk;Zdze vkSj lEesyu ,oa ifjlaokn xks"Bh@ dk;Z'kkyk esa i=
13
(c) Are you willing to accept the initial salary of the grade? (If no, state what is the minimum salary acceptable with
justification thereof).
¼l½ D;k vkidks vkosfnr osrueku dk U;wure Lohdk;Z gS\ ¼;fn ugh] dkj.k lfgr Li"V djsa fd fdruk U;wure~ ewy osru Lohdk;Z gS½A
(d) if appointed, what period would you require before joining the post?
¼n½ fu;qfDr gksus ds fLFkfr esa dk;Z xzg.k djus ls igys fdrus le; dh vko’;drk gS\
(e) Any other relevant information, if not given above:
¼;½ vkosfnr in ls lEcfU/kr vU; dksbZ lwpuk tks Åij u nh x;h gks%
14
(a) Has there been any break in your academic career? If so, give details.
¼v½ D;k dHkh vkidh fo|ksiktZu dk Øe Hkax gqvk\ ;fn gk¡ rks dkj.k lfgr fooj.k nsaA
(b) Have you been punished during your studies at college/University? If so, give details.
¼c½ D;k dHkh vkidks fo|ksiktZu ds nkSjku fo’ofo|ky;@dkyst }kjk n.M fn;k x;k\ ;fn gk¡ rks fooj.k nsaA
(c) Have you been punished during your services or convicted by a court of law? If so, give details.
¼l½ D;k dHkh ukSdjh ds nkSjku vkidks nf.Mr fd;k x;k gS ;k fdlh U;k;ky; }kjk vkidks nks"kh çekf.kr fd;k x;k\ ;fn gk¡ rks
fooj.k nsaA
(d) Were you at any time declared medically unfit or asked to submit your resignation or discharged or dismissed? If yes,
give details in a separate sheet.
¼n½ D;k dHkh vki LokLF; ijh{kk esa v;ksX; ?kksf"kr gq;s] vkils R;kxi= nsus ds fy;s dgk x;k vFkok vkidks fdlh ukSdjh ls ineqDr
;k c[kZkLr fd;k x;k gS\ ;fn gk¡ rks i`Fkd i`"B ij fooj.k nsaA
(e) Do you have any case pending against you in any court of law? If yes, give details.
¼/k½ D;k vkids fo#} dksbZ U;kf;d ekeyk fopkjk/khu gS ;fn gk¡ rks fooj.k nsaA
15
Give names, designations and addresses (Phone/Fax No./e-mail, if any, of three references not related to you. References
should be of persons with or under whom you have worked, or who have intimate knowledge of your work.
rhu lUnHkZ O;fDr;ksa ds uke] muds Mkd irs ¼Qksu] QSDl u- ;fn gS½ ds lkFkA lUnHkZ O;fDr og gksuk pkfg;s ftlds lkFk ;k ftlds
v/khu vH;FkhZ us dk;Z fd;k gks ;k tks vH;FkhZ ds dke ls iw.kZr;k voxr gkaAs
Sl. No./
Ø-la-
Name /uke
Designation/
in uke
Address/
irk
Phone/Fax No./ Mobile No./
Qksu@QSDl u-
eksckbZy u-
E-mail /
bZ&esy
i
ii
iii
16
List of Enclosures/ layXu çys[kksa dh lwph (Please tick in the box ckDl esa lgh dk fu’kku yxk;s½a
(a) Bank Draft & Photograph cSad Mªk¶V ,ao Nk;kfp=
(b) Copies of Mark-sheets & Certificates of educational qualifications & certificate of clearing NET/SLET/JRF etc.
vad&i=ks]a ’kS{kf.kd çek.k&i=ksa ,oa jk"Vªh;@jkT; ik=rk ijh{kk@dfu"d v/;srk ikl djus ds çek.k i=ksa dh Nk;kçfr;k¡
(c) Copies of certificates of experience. vuqHko çek.k i=ksa dh Nk;kçfr;k¡
Applicant’s Signature:
vH;FkhZ dk gLrk{kj %
MKS
3
17
Declaration to be signed by the candidate
I hereby declare that I have carefully read and understood the instructions attached to the advertisement as available on
IIT(BHU) website www.iitbhu.ac.in and that all the entries in this form are true to the best of my knowledge and belief. I
also declare that I have not concealed any material information which may debar my candidature for the post applied for.
In the event of suppression or distortion of any fact like category or educational qualification etc. made in my application
form, I understand that I will be denied any employment in the Institute and if already employed on any of the posts in the
Institute, my services will be summarily terminated forthwith without notice or compensation.
Place : ________________
Date : ________________
(Signature of the Candidate with Date)
?kks"k.kk
eS ;g ?kks"k.kk djrk@djrh gw¡ fd eSus foKkiu] tks fd vkbZ0vkbZ0Vh0 ¼ch0,p0;w0½ ds osclkbV www.iitbhu.ac.in esa miyC/k gS] ds lHkh funs’Z kksa
dks /;kuiwod
Z i<+ fy;k gS ,oa vkosnu i= esa Hkjs x, lHkh fooj.k esjh vf/kdre tkudkjh vkSj fo’okl ds vuqlkj lR; gSA eS ;g Hkh ?kks"k.kk
djrk@djrh g¡w fd eSus dksbZ Hkh egRoiw.kZ lwpuk ugha fNikbZ gS ftlls fd vkosfnr in gsrq esjk vkosnu fujLr fd;k tk ldsA eSa
le>rk@le>rh gw¡ fd vxj Hkjs x, vkosnu i= esa dksbZ Hkh lR;rk tSls tkfr ;k 'kSf{kd ;ksX;rk vkfn fNik;k ;k fo:fir fd;k x;k gks rks eS
laLFkku esa dksbZ Hkh jkstxkj ds fy, vLohdkj fd;k tkÅ¡xk vkSj ;fn eS igys ls gh laLFkku ds fdlh in ij dk;Zjr g¡ rks esjh lsok fcuk fdlh
lwpuk vFkok gtkZus ds rqjUr lekIr dj nh tk,xhA
LFkku %
fnukad %
18
¼vH;FkhZ dk gLrk{kj fnukad lfgr½
Forwarded with the remarks that the institution/organization has no objection to the candidature of the applicant
being considered for the post applied for, as above.
bl vk’k; ds lkFk vxsfz "kr fd vH;FkhZ ds mi;qZDr in gsrq vkosnu djus ,oa bl in ij p;u gsrq fopkj gksus ij
laLFkk dks dksbZ vkifÙk ugha gSA
Place: LFkku
Dated fnuakd
Telephone VsyhQksu
Fax QSDl
e-mail bZ&esy
Signature /gLrk{kj
(Head of the Institution/Organisation laLFkku@laxBu
Designation in
Address irk
Remarks/fVIi.kh%
Candidate already employed should submit application through his/her employer.
fu;ksftr vH;FkhZ vkosnu i= vius fu;ksDrk ds ek/;e ls HkstAsa
MKS
4
izeq[k)
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