Dr.

Shyama Prasad Mukherjee

International Institute of Information Technology – Naya Raipur
Atal Nagar, Raipur, Chhattisgarh - 493661

FORM OF APPLICATION FOR FACULTY APPOINTMENT BY SELECTION

Please read carefully the general conditions / instructions enclosed herewith before filling the form)

Please email the filled application to facultyrecuitment@iiitnr.ac.in Photograph

1. Advt No

2. Post Applied for

3. Department

4. Specialization:

5. Name in full (in capital

letters) (Underline Surname)
6. Father’s / Husband’s Name

7. a. Marital Status b. Male / Female :

8. a. Permanent address b. Address for correspondence (if different from permanent
address)

Mobile No. E-mail ID

9. Date of birth (please attach true copy

of certificate ) and Age
10. Are you having domicile of
Chhattisgarh State?
11. Please state your category (SC/ST/OBC/General)*

12. If you are employed, please state your

present basic pay & scale of pay*

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13. Details of educational qualifications: Please give particulars of all examinations passed and degrees obtained commencing with the High School Leaving Examination (10th standard /
Matriculation). Please attach attested copies of certificates and mark sheets.
Sl. School / College / Institute Date of Date of Name of the Board Examination Distinction Subjects (Please mention field Percentage Year of
No. entry leaving / University / Institution / Degree / / Class / of specialization, honours, etc, of marks or passing
Diploma passed Division where applicable) C.P.I.

14. Details of employments: Please give particulars of your present and past employments in chronological order, starting with the present one*:
Sl. Organisation / Institute Position Nature of duties / work Date of Date of Last Pay & Scale Additional remarks about
No. held joining leaving of pay experience, if any.*

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15. Research & Development, Training, Project, Publication etc. :

(a) Please attach a list of your Sponsored Research & Development / Industrial/Training experience

(b) Please state the following in the format below (give details in a separate sheet):

No. of PG No. of Ph.D. thesis guided No. of Projects involved in No. of Patents
projects guided
Completed On-going Sponsored Consultancy

(c) Please state the number of publications in different categories (Attach a list of publications)

In Journals (SCI) In Conferences (peer reviewd)

Technical
Refereed Un-refereed Reports

16. (a) Teaching Experience No. of Years : No. of different courses taught :

No. of courses as a teaching assistant:

Please give a list of courses taught on a separate sheet with course titles, level (UG/PG) and number of times taught

(b) Areas of specialization in your thesis

(c) Title of your Ph. D. Thesis

(d) Please describe briefly on a separate sheet your Ph.D. work. Also detail the areas of interest with work done in
each case (if any).

(e) Laboratory Experience : Please describe, in brief on a separate sheet, your experience in (i) Setting up teaching
and research laboratories (ii) Conducting laboratory courses & (iii) Using different types of instruments, systems,
computers etc.

(f) Attach SOP on teaching and research

17. Did you previously apply for any post in

this Institute? If so, give particulars and
approximate date :

18. Additional Remarks :

(Applicants may mention here any
special qualifications or experience,
e.g. in organisations which have not
been included under the heads given
above)

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19. Please give a list of at least three referees below, along with their addresses and email addresses. Your PhD
supervisor is expected to be one of the referees. Please request your referees to send their letters of reference
directly to facultyrecuitment@iiitnr.ac.in with the subject: letter of reference for <your name>.

20 Enclosures to be included with the application (if there is

no information for some items, specify that this
enclosure is not included).

I hereby declare that I have carefully read and understood the instructions and particulars supplied to me and that all the entries in this
form are true to the best of my knowledge and belief.

________________________
Date: ................................ Signature of the Candidate