NATIONAL INSTITUTE OF TECHNOLOGY CALICUT

NITC CAMPUS (PO), KOZHIKODE, KERALA-673601 Self-attested

photograph(Ima
(Application Form for Faculty Position) ge Dimension:
150W X 200HPx)
No. P1/456/FR/2015 dated:26/11/2015
Post Applied: Name of the Post AGP

Department:
Specialization:
1. Name in Full: (in capital letter)
2. Father’s / Husband’s Name:(in capital letter)
3. Mother’s Name:(in capital letter)
(a) Date of Birth:
4.
(b) Age as on 01-01-2016:
5. a) Marital Status: Married/Unmarried b) Gender: Male / Female
a) Permanent Address: b) Correspondence Address:

6.

Phone: (with STD code)

E-mail:
Mobile No.
7. Nationality:
OBC-Non-Creamy
(a) Category under which you are seeking SC ST
Layer
PwD
reservation/relaxation:
8.
(b) Percentage of Disabilities for PwD VH OH HH
Candidate:

9. Details of Education Qualification

(a) From SSLC/Matriculation upto PG (Attach Photocopies of Relevant Certificates& Mark Lists)
Exam Board/ Year of Class/ Percent of
Specialization College/ Institute
Passed University Passing Grade Marks/CGPA

Signature of the Applicant

(b) Details of Doctoral Degree (Attach Photocopies of Relevant Certificate)
Degree
College/ Final Viva-
Thesis Title From To University Awarded
Institute Voce Date
Date

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

Nature of Work From To Name of Institution/Organization

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

(a) Teaching: Total (in years and months) ………. Post-Ph.D. (in years and months) ……..
Name and Pay-
S. Type of
Address of Designation Scale& From To Duration
No. Organization
Employer AGP/GP

(b) Industry: Total (in years and months) ………..

Name and Pay-
S. Type of
Address of Designation Scale& From To Duration
No. organization
Employer AGP/GP

Signature of the Applicant

(c) Research: Total (in years and months) ………..
Name and Pay-
Type of
S. No. Address of Designation Scale& From To Duration
organization
Employer AGP/GP

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

Academic experience as applicable Assistant Professor or equivalent
(month / year) in the posts indicated Associate Professor or equivalent
or 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 of the Journal Vol.& Year Pages

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 Journal Vol. & Year Pages

(b)PapersPresented in National/International Conferences (Attach Photocopy of First

Page of Paper)
S. No. Title of the Paper Author(s) Name of the Conference Venue & Date

(c) Details of Ph.D. Students (Guided and Ongoing): (Attach Photocopy of Certificate Page of Ph.D.
Thesis)
Principal
S. Name of Year of Title of the Status
Guide & Co-
No. Student completion/registration Thesis (Completed/Ongoing)
Guide if any

Signature of the Applicant

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

13. Patents and Copyrights (Attach Photocopies for proof)

S. No Title of Patent / Copyright Owners/ Inventors Status Year

14. Books/Monographs/Book chapters Published: (Attach Photocopies of the Title Page)

Name of Year of
S. No. Author(s) Publisher
Book/Monograph/Book Publication
Chapter

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

Schoolsorganized:(Attach Photocopies for Proof)
Sponsoring Agency/Self-
S. No. From To Title of the Program
financed

Signature of the Applicant

16. Professional Training Received / Summer Schools / Winter Schools Attended:(Attach
Photocopies for Proof)
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.
Status Principal
Sponsoring
Title of the Project Period Amount (Completed/ Investigator /Co-
Agency
Ongoing investigator if any

Signature of the Applicant

19. Consultancy Project:(Attach Photocopies for Proof)
S. No.
Status Principal
Title of the
Funding Agency Period Amount (Completed/ Consultant / Co-
Consultancy Work
Ongoing Consultant, 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)

Section/Office/Institute level
S. No. From To Position Held Responsibilities
Committee

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:(Attachseparate sheet
if required)

25. Any other Relevant Information:(Attachseparate sheet if required)

26. Name and Address of two References:

1st Referee 2nd Referee
Name Name
Position Position
Address Address
E-Mail ID E-Mail ID
Phone No. Phone 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 Mr./Ms. --------------------------------------------------------------------- Son/Daughter

of Sri --------------------------------------------------------------------------- is a permanent/temporary/adhoc
employee of 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