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dh lsok ds fy;s vgZd ugha ekus tkosaxs A
 INDIRA GANDHI KRISHI VISHWAVIDYALAYA
College of Agriculture & Research Station, Raigarh
(Details of application fee)
Affix D.D. No. -------------------------------
Latest colored
Passport size Amount ---------------------------------
photograph
Date -------------------------------------

APPLICATION FORM FOR TECHNICAL ASSISTANT/FIELD EXTENSION OFICER-03

CONTRACTUAL BASIS
(FIX PAY Rs.16130/- PER MONTH)

Name of the post and Subject -----------------------------------------------------------------------------------

Advertisement No. ------------------------------------------------------ Serial No. of post -------------------

1. Name in full (in block letters) ----------------------------------------------------------------------------

2. Father’s/Husband’s name ------------------------------------------------------------------------------
3. Address :
(i) Present address (for correspondence) : ---------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
E-mail address -------------------------------------------- Mobile No. -----------------------------
(ii) Permanent home address : ------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------
4. Date of birth ----------------------------------------------- Age -----------------------------------------
(According to Matriculation Certificate) (Enclose self-attested Copy) (As on 16.05.2023)

5. Are you a bonafide resident of Chhattisgarh Yes/No

(If “Yes” please attach a self-attested copy of Domicile Certificate)

01
 6. Place of birth (with name of Village/City, District and State) ---------------------------------------

---------------------------------------------------------------------------------------------------------------

7. (a) Mother tongue --------------------------------------------------------------------------------------

(b) Other language (s) which the applicant can speak, read and write fluently -----------

---------------------------------------------------------------------------------------------------------------

8. Category (UR-Un Reserved/ SC-Scheduled Caste/ ST- Scheduled Tribe/OBC-Other Backward Classes)
-------------------------------------------------------------------------------------------------------------------
(if belong to SC/ST/OBC Category, please enclose a certificate from competent authority)

9. What the applicant is married? (Yes/NO) ----------------------------------------------------

(a) If you are married, marriage date -----------------------------------------------------------

(b) The number of children living -----------------------------------------------------------

(c) If you have more than two surviving child of the last child birth --------------------------------------

10. If you are physically challenged, Type of disability (Please enclose a certificate from competent
authority)

(a) Loco motor impaired :- ----------------------------------------------------------------------------------------

(b) Vision impaired : - ---------------------------------------------------------------------------------------------

(c) Hearing impaired : - ---------------------------------------------------------------------------------------------

02
 11. Examination passed : (Please enclose copies of certificate/degree & marks-sheet/Transcript etc. for each of the examinations)

Examinations Name of Name of the Subject (s) Division Year of Percentage Enclosure Number
the degree/ University/ (Major) obtained Passing of Certificate/ Mark sheet
diploma Institute marks/OGPA Degree transcript
obtained
(i) High School

(ii) Higher
Secondary/Inter-
mediate/ pre-
University

(iii) Bachelor degree

(iv) Master degree

(v) Doctoral degree

(vi) Any other

examination (s)

03
12. Academic Excellence (Enclose copy of certificates)
(i) Medal at UG/PG/Ph.D.
(a) Gold Medal -------------------------------------------------------------------------------------
(b) Silver Medal -------------------------------------------------------------------------------------
(c) Bronze Medal -----------------------------------------------------------------------------------
(ii) Academic Awards ----------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------
(iii) National Fellowships by (JRF/SRF, etc.) -----------------------------------------------------
------------------------------------------------------------------------------------------------------------
13. Publications : Research/Extension (attach complete list in bibliographic form and reprints for proof)

Publication As first author As co-author

(No.) (No.)
(i) Full length Research
Paper/Review article
(ii) Short notes

(iii) Published abstracts in

seminars
(iv) Popular/Extension article

(v) Varieties/Technology/Patent
developed/disseminated

14. Experience: As RA/RF/SRF/JRF/TA/Farm Manager in any University/R&D

organization of repute/Central State Govt. etc. (In reverse chronological order, start from the
latest position held. (Enclose copy of appointment order/experience certificate for proof)

S.N. Name of the Pay Organization Period Experience

Post held Scale (from-to) Year/Month

Total Experience
Year/Month
………………………

04
 15. Performance in extra-curricular activities- NCC/NSS/Games and Sports/Cultural (Inter
University Level) enclosed copy of certificate for proof.
(i)

(ii)

(iii)

16. Additional Remarks, If any : ---------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------
DECLARATION
I declare that the entries made in this application form are true and correct to the best
of my knowledge and belief.

Place ------------------------------
Date ------------------------------- Signature of the candidate

REMARKS OF THE PRESENT EMPLOYER

(in the case of those who are already in service)
The applicant Shri/Ku./Smt./Dr. -------------------------------------------------------------------------
is holding a permanent/temporary post of ---------------------------------------------------- in the scale
of pay Rs. -------------------------------------------------------------------- and his/her present basic pay
is Rs. ----------------------------- per month. His/Her application is forwarded and he/she will be
relieved in case he/she is selected for the post applied for.

Place ------------------------------
Date ------------------------------ Signature
Designation of Officer (with official seal)

05
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