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NATIONAL INSTITUTE OF TECHNOLOGY PATNA

PATNA-800 005 (BIHAR)


(Application Form for Faculty Position belonging to PwD)

Advertisement No. NITP/02/2015


To
The Director
National Institute of Technology Patna
Ashok Rajpath
Patna- 800 005 (Bihar)
Post Applied for
Department
Specialization

Self attested
photograph

DD Number
Amount & Date
Name of issuing bank

1. Name in full (in capital letters)


2. Fathers / Husbands Name
3. Mothers Name
4. Date of birth

Day

Month

Year

Year

Month

Day

(please attach true copy of certificate )

Age on 16.11.2015
5. a) Marital Status : Married/Unmarried
b) Gender : Male / Female
6. a) Permanent address

Phone (withSTD
code)/ Mobile No.

7. Nationality
Religion
8. Category OBC (VH)/GEN (HH)/GEN
(OH)
Percentage of disability
(please attach true copy of certificate )

9. Were you at any time declared


medically unfit; asked to submit your
resignation; discharged or dismissed
from Govt./PSU/ Autonomous Body or
Private Service? If yes, give details in a
separate sheet.

b) Correspondence Address

E-mail ID

10. Details of Educational Qualification (Secondary onwards):


Exam. Passed

Specialization

Board/University

Passing
Year

Class/
Division

% marks/
CGPA

10th
12th
Bachelors Degree
Masters Degree
Ph.D.*
Others (if any)
*Please mention date of award of PhD degree.
11. Thesis/Dissertation topic of
(a) PG __________________________________
(b) Ph D __________________________________________
12. Field of Specialization ______________________________________________
13. Details of employments:
(i) (a) Teaching Experience
S.No.

Name and
address of
employer

Total..

Designation

Payscale

From

Post PhD..
To

Duration
in
yy/mm/dd

Reasons
for
leaving

(b) No. of experiments or computational projects added to teaching laoratories*


(c) No. of courses offered through application of ICT*..
(d) No. of e-learning packages prepared*
*Attach relevant documents

(ii) Industry
S.No. Name and
address of
employer

(iii) Research
S.No. Name and
address of
employer

Designation

Payscale

From

To

Duration
in
yy/mm/dd

Reasons
for
leaving

Designation

Payscale

From

To

Duration
in
yy/mm/dd

Reasons
for
leaving

14. Research Activities: (Specify total No. and attach list of publication in the each category as
per format given)
(a) Paper publications in International Journals
(i) In SCI
S.No. Title of paper
Co-author(s),
if any

Name of the
Journal

Vol. &
Year

Pages

Name of the
Journal

Vol. &
Year

Pages

Name of the
Journal

Vol. &
Year

Pages

(ii) Other than SCI


S.No.

Title of paper

Co-author(s),
if any

(b) Paper publications in National Journals


S.No.

Title of paper

Co-author(s),
if any

(c ) Papers publication in International Conferences


S.No.

Title of paper

Co-author(s),
if any

(d) Papers publication in National Conference

Name of the Conference

Date &
year

S.No.

Title of paper

Co-author(s), if
any

(e) Number of UG and PG students guided / Ongoing


UG
Guided
Ongoing

Name of the Conference

PG
Guided

(f) Details of Ph D Students guided / Ongoing


Year
of
Name of
S.No
award
Title of the Dissertation
Student
of
Ph.D

Ongoing

Status
(Completed/
ongoing)

(g) Patents registered/filed (with registration No. & date)


S.No. Title
Registration

15. Books/Monographs/Book chapters written:


S.No. Name of book/ monograph/
Name of Co- Year of
Book chapters
author, if any Publication
16. Consultancy works undertaken:
S.No
Period
Organization

Date &
year

Nature of Work

Co-supervisor
(if any)

Date

Publisher with
address

Co-consultant, if
any

17. Seminars/Short Term Courses/Summer Schools/Winter Schools organized


Sl No. From
To
Name of the
Sponsored*/ No. of participants
course
Self financed From
From
institutes
Industry
*In case of sponsored course please provide details of sponsoring agency
18. Seminars/Short Term Courses/Summer Schools/Winter Schools attended
S.No. From
To
Institute/Industry
Sponsored by
Name of the

course

19. Sponsored Projects undertaken


Sponsoring Title of the Project
Period
Agency

Amount

20. Membership of Professional Bodies


S.No. Name of Professional
Grade of
Bodies
membership

21. Administrative Positions held / Continuing


S.No.
From
To
Position held

Completed/
ongoing

Accomplishment

Membership no. with validity

Responsibilities

22. Other information:


(i) Prizes/Medals/Awards/Distinctions:..
(ii) Scholarship received:
(iii) Sports and extra-curricular activities (including N.C.C.)
(iv) Knowledge of foreign languages:
(v) Any other relevant information.
(For each of the above items, please give full details in separate sheets)

23. Name and address of two References:


2nd Reference

1st Reference
Name

Name

Position

Position

Address

Address

Phone No.
E-Mail ID

Phone No.
E-Mail ID

24. Did you previously apply for any post in this Institute? If yes, give particulars:
.

APPLICANTS DECLARATION
I hereby declare that I fulfill the eligibility conditions to the post and that the statements
made by me in form are true, complete and correct to best of my knowledge and belief.
Place:.

Signature of Applicant

Date..
Name
NO OBJECTION CERTIFICATE TO BE FURNISHED BY THE CANDIDATE WHO IS
ALREADY IN EMPLOYMENT, REGULAR/TEMPORARY BASIS.
Certified that Mr/Ms.--------------------------Son/Daughter of Shri---------------------------------------------is a permanent /temporary /adhoc employee of the department/ institution/
organisation since-------------------------------. The Department/Institution/organisation has
no objection if he/she is appointed in National Institute of Technology Patna against the
posts advertised by the NIT Patna vide advertisement No.

Signature with seal


Place:--------------------------Date:----------------------------