Advertisement No. : 02/2015 Name of the News paper : ___________________________________ Space for affixing Passport size recent Photograph DHENKANAL SCIENCE CENTRE (National Council of Science Museums) Near Rajbati, Dhenkanal – 759 001 ************************************************ Form of application for the post of Education Assistant ‘A’ (Pure Science) D.D. No._______________________ and Date_____________ Amount ___________ Name of the drawee Branch ______________________________________________ ( To be filled in by the candidates with own handwriting and forwarded to the above address ) --------------------------------------------------------------------------------------------------------------------------01. Name in full (in block letters) : -------------------------------------------------------------------------------------------------------------------------02. Address in full : Present : Permanent : Email ID : --------------------------------------------------------------------------------------------------------------------------03. a) Date of birth : ( in Christian era ) b) Place of birth : --------------------------------------------------------------------------------------------------------------------------04. Are you YES / NO * a) a citizen of India by birth and/or by domicile ? b) a person having migrated from Pakistan or Bangladesh or other countries with the intention of permanently settling in India ? or subject of Nepal or Sikkim ? * Answer ‘Yes’ or ‘No’ and cancel the words, which are not applicable. --------------------------------------------------------------------------------------------------------------------------05. Name of the State to which you belong : --------------------------------------------------------------------------------------------------------------------------- : 2 : 06. a) Father’s Name : b) Address c) Occupation : : d) Mother’s Name : e) Address : f) Occupation : ( If dead, state his/her last address and occupation before death ) -------------------------------------------------------------------------------------------------------------------------07. Is or was your father/mother : (a) a citizen of India by birth and/or by domicile ? (b) a person having migrated from Pakistan or Bangladesh or other countries with the intention of permanently settling in India or a subject of Nepal ? * Answer ‘Yes’ or ‘No’ and cancel the words, which are not applicable. -------------------------------------------------------------------------------------------------------------------------08. State your (a) Religion : (b) Are you a member of Schedule Caste or Tribe or Other Backward Class ? Answer ‘Yes’ or ‘No’. If the answer is ‘Yes’ indicate caste. : (c) Are you physically challenged? If yes, give details : (d) Are you an Ex-Serviceman? If yes, give details : ---------------------------------------------------------------------------------------------------------------------------09. Particulars of all examinations passed and degrees and technical qualifications obtained at the university or other places of higher technical education (commencing with the Madhyamik or its equivalent examination). Examination or Degree or Diploma Name of Board/University Class or Division Subjects taken Year of passing : 3 : ---------------------------------------------------------------------------------------------------------------------------10. Any additional qualifications such as membership of Scientific Societies may be mentioned here. ---------------------------------------------------------------------------------------------------------------------------11. Have you been outside India/If so, give following particulars : Country visited Date of visit Duration of visit Purpose of visit 12. If you are/were a full time researcher, give the following particulars : Name of the Institution Date of joining Date of leaving Area of research Stipend/ Scholarship No. of papers published 13. What language (including Indian language) you can read, write or speak. Give particulars and state any examinations passed in each. Read only Speak only Read and speak Read, write and speak Examination passed, if any 14. Details of previous employment : Name of Organisation Date of joining Date of leaving and reasons therefore Designation and Nature of work Salary and Grade : 4 : 15. Are you employed in a Govt./Autonomous organization at present ? (Answer ‘Yes’ or ‘No’) If yes, state whether your appointment is temporary or permanent. ---------------------------------------------------------------------------------------------------------------16. Are you willing to accept the minimum initial pay offered ? If not, state what is the lowest initial pay that you would accept in the prescribed scale. --------------------------------------------------------------------------------------------------------------17. If selected what notice would you require before joining Immediate/One month/Two months/Three months ---------------------------------------------------------------------------------------------------------------18. Have you any relative working in the NCSM ? If so, please give details. ---------------------------------------------------------------------------------------------------------------19. Are you willing to work anywhere in India ? ( Answer ‘Yes’ or ‘No’ ) ---------------------------------------------------------------------------------------------------------------20. References : (They should be residents in India and holders of responsible positions. They should be intimately acquainted with the applicant’s character and work but must not be relations. When the candidate has been in employment, he should either give his present or most recent employer or immediate superior as referee or produce testimonial from him in regard to the candidate’s fitness for the post for which he is an applicant) (i) Name : Occupation or position : Address : (ii) Name : Occupation or position : Address : (iii) Name : Occupation or position : Address : : 21. In Case of Ex-Serviceman a) Pension Payment Order No. : b) ECHS Card No. : 22. PAN /AADHAR no. if any, : 5 : -------------------------------------------------------------------------------------------------------------------------Note : 1. Information in respect of Columns 3a, 8b, 8c, 8d, 9, 14, 21& 22 should be supported by attested copies of certificates and testimonials, otherwise the application will not be considered 2. Canvassing in any form and/or bringing in any influence political or otherwise, will be treated as a disqualification for the post. -------------------------------------------------------------------------------------------------------------------------I hereby declare that the information furnished in this application is true & correct to the best of my knowledge and belief. Date : Candidate’s signature_____________________________________ (Telephone No., if any : Candidate already employed should get the following endorsement signed by his/her present Employer. ENDORSEMENT BY THE PRESENT EMPLOYER (if he/she is Govt. employee) Date______________________________________ Name_____________________________________ Full signature ______________________________ with seal File No._______________________