Indian Institute of Management Raipur
Government Engineering College Campus
Old Dhamtari Road, Sejbahar, Raipur 492015
Tel: +91-771 - 2772000 Fax: +91-771 - 2772100
Affix your
Passport Size
Photograph
here
Application Form
1. Name in Full:
___________________________________________________________
2. Fathers/Husbands Name:______________________________________________________
3. Date of Birth:
_____/_____/_______ Age as on 01.07.2013 ______ yrs _____months
4. Mailing Address:
___________________________________________________________
___________________________________________________________
Tel. No. _____________________
Mobile: _______________________
Fax No. _____________________
E-mail: _______________________
5. Permanent Address: __________________________________________________________
___________________________________________________________
Tel. No. _____________________
Mobile: _______________________
6. (a) Position Applied for: _______________________________________________________
(b) Area of Specialization: _____________________________________________________
(c) Did you previously apply for any post in this Institute?
Yes_____
No _____
If yes, please provide details: ________________________________________________
7. (a) Gender (M/F): ____
(c)
(b) Marital Status: _____________ (c) No. of dependents: ______
Details of Family
S.No.
Name
Relation with
employee
Age
Profession
8. Nationality: _________________________________________________________________
9. Category (SC/ST/OBC/DAP/General):
_______________________________________
10.
Objectives for applying at IIM Raipur
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
11.
Subject(s) Currently Teaching at PG/Doctoral level:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
12.
Area of Research Interests:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
13. Topic of your FPM/Ph.D. /Equivalent
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
14. Educational Qualifications recognized by AIU/UGC/any other statutory body or
parity (in reverse chronological order)
Sl.
No.
Examination
Passed
University/ Institution
Subjects
Year
of
passing
%age of Class/
Marks Division
1
2
3
4
5
6
7
15. Full time Work Experience (in reverse chronological order)
Sl.
No.
Name of the
Employer
Period of Service
From
To
Position/
Designation
Scale of
Pay &
Basic
Pay
Reason for
leaving
(a) Total work experience: _________________ years
(b) Total Post-Ph.D. Teaching Experience at P.G. level: ____________ years
(c) Total Work Experience as Assistant Professor/Associate Professor: _____________ years
16.
Details of Publications and Research works (Please attach separate sheet if necessary):
(a) Research Papers Published
S.
Co-authors
Year
Title of Paper
No.
Journal
Vol.
No.
pp.
If required, please attach separate sheets if in same format.
(b) Books Authored/edited
S.
Name of Book
No.
Co-authors
(c ) Papers Presented in the Conference
S.
Co-authors
Year Title of Paper
No.
Publisher
Conference
Year of
Publication
Organised
by.
(d) Research Project Undertaken
S.
Name of Research Project
No.
(e) FPM/Ph.D. Supervision:
S.
Scholars
Year
No.
Name
of
Regn.
Co-Investigator
FPM/Ph.D. Topic
Funding Agency/Amount
University/
Institution
Co-super
-visor(s)
Status
Status
17. MDPs/Workshops/Seminars/Consultancy conducted:
Sl.
No.
1
Topic of MDP
Duration
Dates
Organisation/Place
2
3
4
5
18.
Experience of Administrative Responsibilities in Academic Institutions:
From
19.
To
Administrative
Position
Major responsibility
Any other information you may wish to add:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
20.
21.
Professional References (Two)
E-mail: _________________________________
E-mail:_________________________________
Mobile: _________________________________
Mobile: _________________________________
Declaration:
I declare that the foregoing information is correct and complete to the best of my knowledge
and belief and nothing has been concealed/ distorted. If I am found to have
concealed/distorted any material information, my application shall be liable to summarily
termination without any notice. If offered appointment, I will join on specified date and
subsequently take up IIM Raipurs assignment anywhere as and when required.
Date:
Place:
Signature of the Candidate
