VISVESVARAYA TECHNOLOGICAL UNIVERSITY

JNANA SANGAMA, BELGAUM- 590 018, KARNATAKA STATE.

APPLICATION FOR TEACHING POST / zsP

zU PwAi Cf
(submitted in Five Sets / Lz wU P)

(Please type or write in BLOCK LETTERS)

Advertisement No./
CZ AS

Affix your Recent

Passport size photo/

Post Applied For

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Course

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1. Name in Full /

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a) Fathers Name /
Husbands Name

vAzAi/UAq g
Male/

b) Gender/AU

Female/

UAq
Married
/v

c) Marital Status/ P

t
Un Married
/Cv

d) Category (Tick mark to be made) /U (Az Ugv Pz)

SC
ST
Cat. I
Cat. IIA
Cat. IIB

. e

. A.

U-1

U-2J

U-2

Horizontal Reservation / M w
2. Address for correspondence / CAZ :

Mobile /
Telephone

Office

(STD-Code)
Res. No.

zgt
E-mail/ E-
3 a. Date of Birth:

3 b. Nationality
/ gAiv

d AP
Day

Month

Year
Page 1 of 6

Cat. IIIA

Cat. IIIB

GM

U-3J

U-3

.C.

4. Present Employment Details / v zAi g:

Designation
Organization
Scale of Pay with AGP/GP Rs.
Current Basic Pay Rs.
Total emoluments (per month) Rs.
5. Areas of specialization:

____________________________________________________________________

6. Title of the Thesis : i) P.G.

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ii) Ph.D. __________________________________________________________________

__________________________________________________________________
__________________________________________________________________
7. Academic Record starting with SSLC / PtP zvAi gU JJJ EAz: (Attach photocopies)
Certificate/
Degree

Specialization

Board/College/Institute/ University

Year of
Percentage/
completion
CGPA

8. Employment/ Ai gU: (Particulars of your employment in chronological order starting with recent
employment/

z gU Attach photocopies)

Employer

Post held

Page 2 of 6

Date of
Joining

Date of
Leaving

Gross
Salary

Pay
Scale

9. Academic Experience /PtP Cs: (from & to ) (Enclose supporting documents)

Lecturer
Academic experience as applicable
(month / year) in the posts indicated
or equivalent

Assistant Professor
Associate Professor
Professor

10. Experience / Cs: (in no. of years) (Enclose supporting documents)

Teaching experience

UG :

PG :

Research experience (Post-Ph.D.)

Industrial experience

11. Research guidance

(total numbers in last 5 years)

Completed
Ph.D.

Ongoing
P.G.

Ph.D.

P.G.

12. Publication details: (total numbers during last 5 years) (Attach re-prints of 3 best journal papers)
International

National

Journal papers
Conference publications
13. Books / Chapters published & E-learning
materials Developed (last 5 years)
14. Patents
(last 5 years)
15. Sponsored Projects (Number & Amount)
(last 5 years)
16. Consultancy Projects (Number & Amount)
(last 5 years)
17. Professional Training Received / Summer / Winter Schools attended:
(Last five years - Attach photocopies)
Year

Nature of Training

Duration

Page 3 of 6

Organization where
training was provided

18. Conferences / Seminars / Workshops attended: (Last 5 years - Attach photocopies of the certificates)
Year

Conferences / Seminars /Workshops attended

Title of paper presented

19. INDUSTRIAL EXPERIENCE: (Attach photocopies)

Organization

Nature of work

Period

20. CONTINUING EDUCATION PROGRAMMES / SHORT TERM COURSES/ WORKSHOPS / SEMINARS ETC.
ORGANIZED: (Last 5 years)
Title of Programme

Period

Funding Agency

21. PROFESIONAL MEMBERSHIP AWARDS AND RECOGNITION: (Attach photocopies)

22. EXPERIENCE IN ADMINISTRATIVE POSITIONS, CURRICULUM AND LAB DEVELOPMENT, STUDENT

WELFARE, PROFESSIONAL AND OUTREACH ACTIVITIES:

23. ANY OTHER RELEVANT INFORMATION YOU MAY LIKE TO FURNISH:

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24. Names and addresses of two Professional References:

Name

1.

2.

Position
Address

Phone & Fax

Mobile
E-mail

25. Details of application fees Paid / wg g:

DD No./ r.r. AS

DD Date / r.r. AP

Bank Name /AQ g

Amount / v
Rs.___________

26. I hereby declare that the entries in this form are true to the best of my knowledge and belief.
I understand that my candidature will be cancelled if any of the information is found to be false or
incorrect. Further, if selected, I will abide by the rules and regulations of VTU and also the directions
given to me from time to time.
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Date/ AP :
Place/ :

..............................................................
Signature of Applicant/ Cs yAi

____________________________________________________________________________________________
List of Self Attested enclosures/ Uwz zRwU gU: ( certificates / testimonials (tick the appropriate ones)
1. Proof of Date of Birth
2. Demand Draft (DD)
3. Category certificate (SC/ST/OBC/PH)
4. Salary certificate / pay slip
5. Academic records (SSLC marks card onwards up to Ph.D.)
6. Experience certificates
7. Training / Summer / Winter Schools attended
8. Conferences / Workshops attended and presented papers
9. Sponsored and consultancy projects
10.Workshops / Conferences / Short Term Courses organized
11.Publication and Patents details (list and reprints)
12.Awards and recognitions
13.Testimonial
14.Self addressed 11 X 5 size enveloppes 2 Nos.
______________________________________________________________________________________________

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CERTIFICATE TO BE FURNISHED BY THE STATE/QUASI GOVT. SERVANTS

Certified that Sri / Smt ...holds a permanent /

temporary post under the State/Quasi Govt. as ...(Designation) in the dept.
of . from having been appointed therein under the rules of recruitment. He /She
is permitted to apply for the said post.

Place :

Signature of the appointing authority

Date:

of the department / with name and seal

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