INDIAN INSTITUTE OF TECHNOLOGY BHUBANESWAR

Samantapuri, Bhubaneswar-751 013 APPLICATION FORM FOR APPOINTMENT BY SELECTION (Non-Academic Positions)

1.

Name in full (in capital letters) (underline surname) Paste Photograph here

2.

Fathers / Husbands Name a. Marital status a. Permanent address b. Male / Female b. Address for correspondence

3. 4.

Phone No. (with STD code) Mobile No. 5. a) Post applied for b) Advt. No.

E-mail ID

c) Did you previously apply for any post in this Institute? If so, give particulars and approximate date: If you wish to apply for more than one post, please send separate applications for each post. 6. 7. 8. 9. 10. Date of birth (please attach self attested copy of certificate ) a) Citizenship Category (SC/ST/OBC/PH/General) If selected, how much time would you need to join? If employed, state your present basic pay & scale of pay / PB &GP b) State of domicile

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11. Details of educational qualifications: Please give particulars of all examinations passed and degrees obtained commencing with the High School leaving (10th standard / Matriculation) Examination. For Ph.D., please give details, even if it is not complete. Please attach self attested copies of certificates and mark sheets. Sl. No. School / College / Institute Month and Year Of entry Month and Year of leaving Name of the Board / University / Institution Examination Distinction Subjects (Please mention field Percentage / Degree / / Class / of specialization, honours, etc., of marks where applicable) Diploma passed Division Year of passing

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

-3Designation and 1. 13. Name, Address (along with P h o n e No. / Email) of referees who are acquainted with your work. 2.

14. 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)

15. Details of enclosures sent with the application

1 2 3

4 5 6

16. Details of Demand Draft

Name of issuing bank DD No Amount

Place : Date of Issue :_

I hereby declare that the information furnished in the application are true, complete and correct to the best of my knowledge and belief. I am fully aware that in the event of any information being found false or incorrect at any stage, my candidature / appointment is liable to summary cancellation / termination without any notice or any compensation in lieu thereof.

Date: ................................

Signature of the Candidate