Vous êtes sur la page 1sur 10

NATIONAL INSTITUTE OF TECHNOLOGY CALICUT

NITC CAMPUS (PO), KOZHIKODE, KERALA-673601


(Application Form for Faculty Position)

No. P1/456/FR/2015 dated: 26/11/2015


Post Applied:

Name of the Post

Department:
Specialization:
1. Name in Full: (in capital letter)
Fathers / Husbands Name: (in
2.
capital letter)
3. Mothers Name: (in capital letter)
(a) Date of Birth:
4.
(b) Age as on 01-01-2016:
5. a) Marital Status: Married/Unmarried
a) Permanent Address:

Selfattested
photograph
(Image
Dimension:

AGP

b) Gender: Male / Female


b) Correspondence Address:

6.

7.
8.

Phone: (with STD


code)
Mobile No.
Nationality:

Email:

(a) Category under which you are


seeking reservation/relaxation:
(b) Percentage of Disabilities for PwD
Candidate:

SC

ST

OBC - NonCreamy Layer

VH

OH

PwD

HH

9. Details of Education Qualification


(a) From SSLC/Matriculation upto PG (Attach Photocopies of Relevant
Certificates & Mark Lists)
Exam
Passed

Specializatio
n

College/
Institute

Board/
University

Year of
Passing

Class/
Grade

Percent of
Marks/CG
PA

Signature of the Applicant

(b) Details of Doctoral Degree (Attach Photocopies of Relevant Certificate)


Thesis Title

From

College/
Institute

To

University

Final VivaVoce Date

Degree
Awarde
d

(c) Details of Post-Doctoral Work (Attach Photocopies for Proof)


Nature of Work

From

Name of
Institution/Organization

To

10. Details of employments / experience: (Attach Photocopies for Proof)


(a) Teaching:

Total (in years and months) . Post-Ph.D. (in years

and months) ..
S.
No
.

Name and
Address of
Employer

Designati
on

(b) Industry:
S.
No.

Name and
Address of
Employer

PayScale &
AGP/GP

From

To

Durati
on

Type of
Organizati
on

Total (in years and months) ..


Designati
on

PayScale &
AGP/GP

From

To

Duratio
n

Type of
organizati
on

Signature of the Applicant

(c) Research:
S.
No.

Name and
Address of
Employer

Total (in years and months) ..


Designati
on

PayScale &
AGP/GP

From

To

Durati
on

Type of
organization

(d) Summary of Teaching Experience: (Number of Years and/or months)


Academic experience as

Assistant Professor or

applicable (month / year) in

equivalent
Associate Professor or

the posts indicated or


equivalent

equivalent
Professor

11. Details of Experiments/Computational projects added to teaching


laboratories/ Courses offered through application of ICT/E-learning
packages prepared:

12. Research Publications:


(a) Papers published in National / International Journals: (Attach Photocopy of
First Page of Paper):
(i) In SCI/SSCI Journals
S. No.

Title of the Paper

Author(s)

Name
Journal

of

the

Vol.
Year

&

Page
s

Signature of the Applicant

(ii) In Scopus Indexed Journals - Other than those listed in (i) (Attach Photocopy
of First Page of Paper):
S. No.

Title of the Paper

Author(s)

Name

of

the

Vol.

Journal

&

Year

Page
s

(b) Papers Presented in National/International Conferences (Attach Photocopy


of
First
Page of Paper)
S. No.

Title of the Paper

Author(s)

Name

of

the

Conference

Name of

No.

Student

Year of
completion/registr
ation

Title of the
Thesis

&

Date

(c) Details of Ph.D. Students (Guided and Ongoing):


Certificate Page of Ph.D. Thesis)
S.

Venue

(Attach Photocopy of
Status

Principal

(Completed/

Guide & Co-

Ongoing)

Guide if any

(d) Number of UG and PG Project/Thesis - Completed / Ongoing: (Attach


Photocopy of Certificate Page of UG Project Report / PG Thesis)

Signature of the Applicant

UG

PG
Ongoing

Completed

Ongoing

Completed

13. Patents and Copyrights (Attach Photocopies for proof)


S.

Title of Patent / Copyright

Owners/ Inventors

Status

Year

No

14. Books/Monographs/Book chapters Published: (Attach Photocopies


of the Title Page)
S.
No.

Name of
Book/Monograph / Book
Chapter

Author(s)

Year of
Publication

Publisher

15. Seminars/Conferences/Short Term Courses/Summer Schools/Winter


Schools organized: (Attach Photocopies for Proof)
S.
No.

From

To

Title of the Program

Sponsoring
Agency/Self-financed

16. Professional Training Received / Summer Schools / Winter Schools


Attended: (Attach Photocopies for Proof)

Signature of the Applicant

S.
No.

Year

Nature of Training

Duration

Organization
where training
was provided

17. Seminars/Conferences/ Workshops attended: (Attach Photocopies


for proof)
S.
No.

From

To

Title of the program

Organized by

Date

18. Sponsored Project: (Attach Photocopies for Proof)


S.
No.

Sponsoring
Agency

Title of the
Project

Perio
d

Amou
nt

Status
(Complet
ed/
Ongoing

Principal
Investigator /
Co-investigator
if any

19. Consultancy Project: (Attach Photocopies for Proof)

Signature of the Applicant

S.
No.

Funding
Agency

Title of the
Consultancy
Work

Perio
d

Status
(Complet
ed/
Ongoing

Amou
nt

Principal
Consultant / CoConsultant, if
any

20. Fellowship/Membership of Professional Bodies: (Attach


Photocopies for Proof)
S. No.

Name of Professional
Body

Grade of Membership

Membership No.

21. Administrative/Institute Support Work: (Attach Photocopies for


Proof)
S.
No.

Section/Office/Institute level
Committee

From

To

Position Held

Responsibilitie
s

22. Details of Academic Outreach Activities: (Attach Photocopies for


Proof):

23. Awards / Distinctions won: (Attach Photocopies for Proof)

Signature of the Applicant

24. Please State Your Teaching and Research Plan for the Next Five
Years: (Attach separate sheet if required)

25. Any other


required)

Relevant

Information:

(Attach

separate

sheet

if

26. Name and Address of two References:


1st Referee

2nd Referee

Name
Position
Address
E-Mail

Name
Position
Address
E-Mail

ID
Phone

ID
Phone

No.

No.

27. Did you previously apply for any post in this Institute? If yes, give
particulars: (not applicable for internal candidates)

Signature of the Applicant

DECLARATION
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 the institute and also the directions
given to me from time to time
Place: .

Signature of the

Applicant
Date: ..
Name: ..

NO-OBJECTION CERTIFICATE TO BE FURNISHED BY THE CANDIDATE WHO IS


ALREADY IN EMPLOYMENT ON REGULAR/TEMPORARY BASIS. (For internal
candidates, No-Objection Certificate is not required)
Certified
---------------------------------------------------------------------

that

Son/Daughter

--------------------------------------------------------------------------permanent/temporary/adhoc

employee

Mr./Ms.
of

Sri

is
of

a
the

---------------------------------------------------------------------------------------------------------------------------department/institution/organization

since-----------------.

The

Department/Institution/ organization has no objection if he/she is appointed in


National Institute of Technology Calicut against the posts advertised by the NIT
Calicut vide advertisement No. .
Place: ------------------Date: --------------------

Signature & Seal of Forwarding Authority

Signature of the Applicant

Signature of the Applicant