Maulana Azad
NATIONAL INSTITUTE OF TECHNOLOGY
BHOPAL-462 003 MP INDIA
Note: Prospective candidates are advised to study the Instructions carefully and then fill up the application precisely
and to the point in all respects. No column should be left blank. Incomplete application will be rejected
rejected. Candidate
may attach
ttach additional sheets, if required. No Certificates/ Testimonials should be attached along with application
except Demand Draft.
Advertisement No:
AB/Estt/2017/431
APPLICATION FORM
Date:
( for Faculty Positions) 16/06/2017
Last Date of
07/07/2017
submission
Post Applied For Academic
Grade Pay
Department
FEE REMITTANCE
Affix recent passport size
Issuing Bank & photograph
its Branch duly signed by candidate
DD No & date
Amount
If exempted,
reason thereof
1 Personal Information
Name of Applicant
( in full capitals)
Fathers name
Mothers Name
Spouse Name
Date of Birth & Age DD MM YY Years Months Days
(As on last date of Age
receipt of Application )
Nationality Religion
Caste Caste
Category
Whether Physical % of
Challenged Yes/No Disability
Gender Marital Status
Identification No
Aadhar
Passport/ Aadhar / Voter ID
/ Driving License (specify
any two)
Complete Postal address with Pin code
For Correspondence Permanent
Other Contact information
Phone No R Mobile 1
with STD
Code O Mobile 2
e-mail
2 Educational Qualification ( 10th Std onwards)
Examination Board Subject Group/ Year of % of Grade
Trade passing Marks
High School or
equivalent
Higher Secondary or
equivalent
Diploma
(if any)
3 Educational Qualification ( UG Degree onwards)
Degree/Diploma Subject / University/ Institution % of Grade Year of
discipline Marks passing
4 PhD Qualification
Date of Whether Full Discipline/ University/ Date of Date of
Registration time or Part Department Institution thesis Award
time submission
Title of Thesis
Paper published in 1
the area of research
during the course of
PhD with impact 2
factor
5 Post Doctoral Fellow Qualification
Date of Discipline/ University/ Duration of PDF
Registration Department Institution From To
Area of Research
Paper published in 1
the area of research
during the course of
PDF with impact 2
factor
6 Whether qualified UGC- NET/ SLET ( All India Level)
UGC-SLET UGC- NET
Subject Subject
Registration No. Registration No.
Roll Number Roll Number
Year of Passing Year of Passing
7 Research/ Academic Achievements ( if any)
Patent----- (Please tick) File No Date Brief Description of Patent
WIPO/ PCT
Others
Awards Organization Description
International
National
State
NCC
Others if any
8 Higher Education Teaching Experience ( starting with the most recent)
Note: Experience of Visiting/ Guest Faculty paid on hourly/ session basis not to be included. Research/ Teaching
experience obtained during the study of M Phil/ PhD no to be included.
Institute/ Post Duration Experience PB & Gross Temp/
University From To Y M G-Pay Salary Regular/
Permanent
a.
b.
c.
Total
9 School Education Teaching Experience ( starting with the most recent)
Note: Experience of Visiting/ Guest Faculty paid on hourly/ session basis not to be included.
Institution Post Duration Experience PB & Gross Temp/
From To Y M G-Pay Salary Regular/
Permanent
a.
b.
c.
Total
10 Main Subjects taught in last five years.
Subject Subject
1 2
3 4
5 6
7 8
9 10
11 12
11 Scientific Research / Industry Experience.
Organization Post Duration Experience Permanent/
From To Y M Temporary/
Contract/
a.
b.
c.
Total
12 Administrative Experience
Organization Post Nature of Duration Experience Whether overlapping
Responsibility From To Y M with teaching/
Research experience
Yes/ No
a.
b.
c.
d.
Total
13 Research Projects undertaken
Name of Project Title Amount Period of Status
sponsoring Agency Sanction Project Completed/
From To ongoing
a.
b.
c.
d.
14 Thesis Supervision/ Guidance
(List of Candidates shall be furnished along with details of Title of thesis and Year of award)
Independent Experience in Awarded Under Submission In progress
guiding Research Students ( In figures) ( in figures) ( in figures)
a. PhD
b. M. Phil/ M Tech.
15 Books Publication
*(Author Position- Single or Jointly)
Title of Books Author Publication ISBN
Position* (if any)
a.
b.
c.
d.
e.
16 Research Publications (other than during the course of Ph. D and PDF) (Paid Journals are not allowed)
*(Author Position- Single or Jointly)
Title of Paper Author Name of Year ISSN Impact
Position* Journal / (if any) Factor
Conference
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
17 Refresher/Orientation Courses/Training programme, FDP, MDP etc., attended
(Programme less than a week not to be included)
Conducting Organization Title of programme Duration of programme
From To
a.
b.
c.
d.
18 National / International Symposium/ Workshops/ Conference organized by the Applicant as an
Organizing Secretary/Coordinator. (Proof should be countersigned by the Head of Institution/ Dean/ HoD)
Title Name of Sponsor Duration
From To
a.
b.
c.
d.
19 National / International Winter/ Summer Schools organized by the Applicant as an Organizing
Secretary/Coordinator. (Proof should be countersigned by the Head of Institution/ Dean/ HoD)
Title Name of Sponsor Duration
From To
a.
b.
c.
d.
20 Character & Antecedents Report
Subject Comments
a. Have you ever been subject to any disciplinary
action, as a student and/or as an employee, If so
give full details.
b. Have you ever been dismissed/suspended from
service/employment, if so please give full
details
c. Were you involved in any criminal case, If yes,
give full details (like Crime No, Police Station,
Section under which crime was registered,
acquittal or conviction/ date of order and Case
No)
d. Is any criminal case pending against you in the
court, If yes, give full details
21 Name and Address of minimum two Referees.
(Referees should be familiar with your academic/ Professional Work and should not be relatives)
Name & address Name & address
Phone No Phone No
Mobile No Mobile No
E-mail E-mail
22 In other relevant information in support of candidature
23 Total Credit Points earned as per credit point system
24 Details of Present employment and Employers endorsement
(Candidate may produce NoC in lieu of this endorsement at the time of Interview)
Name of
Organization
Designation Date of
Appointment
Whether Regular Signature of Forwarding authority with seal and date
Permanent/
Temporary
Pay-band
Pay-in-PB
AGP
Basic
Name
Designation
25 Expected Salary/ Pay Protection sought with due Justification for consideration by Selection
Committee.
Expectation Justification
Pay-in-PB
AGP
Basic
DECLARATION
I hereby declare that I have read carefully and understood the instructions and particulars
supplied to me, and that all entries in this form, as well as, in attached sheets are true to the best of my
knowledge and belief. At any stage if any of the information furnished by me is found to be false or
incorrect, suitable action may be taken against me. If selected, I promise to abide by the rules and
regulations of the Institute.
Date:
Place:
Signature
