THE GANDHIGRAM RURAL INSTITUTE DEEMED UNIVERSITY
Under sec.3 of UGC Act 1956 vide Notification No.F.9-1/76-U.3 dated 03.08.76
GANDHIGRAM -624 302, DINDIGUL DISTRICT, TAMILNADU
RE-ACCREDITED BY NAAC WITH A GRADE
Advertisement No.1/Estt.2/2011-12 Advt. Date:10.11.2011 ([Link])
Affix a passport size photograph here duly signed by you
Separate Application form should be used for each post. Please see the general instructions before filling up the Application Form
APPLICATION FOR THE POST OF ___________________________________ _________________________________________________________________ 1. Name in full (Block Letters) : ___________________________________________
2. Name and address of Father/Mother/ :____________________________________________ Husband (in case of married woman) ____________________________________________ ____________________________________________ PIN:____________________ 3. (a) Address to which communications : ____________________________________________ are to be sent ____________________________________________ ____________________________________________ PIN: _____________________ (b) Permanent address : ____________________________________________ ____________________________________________ ____________________________________________ PIN: _____________________ e-mail id:_____________________________________ (c ) Contact Phone No:_____________________Mobile No:__________________________ 4. Gender 5. Nationality and Religion 6. Date of birth and age (a) Place of birth
(a copy of proof should be attached)
: Male/ Female : ____________________________________________ : _______________________________________years : ____________________________________________ : ____________________________________________
Signature of the Candidate
(b) District and State
7. (a) Community
: ____________________________________________ Yes/No
(b) Whether the applicant belongs to SC/ST/OBC : SC/ST/OBC
(Certificate obtained from Revenue Official not below the rank of Deputy Tahsildar should be attached as evidence)
(b) Whether the applicant belongs to Physically Handicapped category : Yes/No
(Certificate obtained from competent Medical Authority should be attached as evidence)
If Yes OH / VH Disability(%) __________
8. Educational qualifications : th (a) 10 Std onwards Examination Board SSLC/Matric or equivalent PUC/+2 (HSc) or equivalent Diploma (b) UG Degree onwards Sl. Degree Subject/ Specialization No.
Month & year of passing
Marks obtained
Overall percentage
Class /Division
University/ Institute
Percentage/ Class/Grade
Year of Passing
(Enclose attested copies: Start from the most recent degree and list upto Matriculation or SSLC)
9. Whether qualified NET/SLET/SET : Yes/No/Exempted If Yes, give details (a copy of proof should be attached) (a) Subject : ____________________________________________ (b) Regn. No. and Year of passing : ____________________________________________ (c) Academic Distinction, if any : ____________________________________________ (eg., any prize, medal, certificate of merit with area of specialization)
Signature of the Candidate
10.(a) * Teaching experience: (starting with the most recent) No. Institute/ Designation Duration Length of University service in From To years 1. 2. 3. 4. 5. 6. * Experience as Guest Faculty is not to be included (b) Administrative/Research experience: Post held with scale of pay Period From To Name of Institution
Whether UG/PG
Permanent/ Temporary/ consolidated
Nature of Duties
11. Present employment (a) Name of the Organization (b) Post held (c) Grade (d) Pay Band (e) Date of Appointment
:____________________________________________ : ___________________________________________ : ___________________________________________ : ___________________________________________ :___________________________________________
(f) Whether Permanent/Temporary/ or on Probation : ___________________________________________ (g) Whether State/Central Govt./ PSU/Private : ___________________________________________ 12. Membership in Professional Societies : _____________________________________
(Name of the Society and Country of incorporation)
13. Post Doctoral Fellowship, if any (National/International): No. Name of Award/ Fellowship Name of Institute/ University
Duration of the program
Special Distinction If any
Signature of the Candidate
14. Research Project undertaken: Sl. Sponsors name Project title No. 1. 2. 3. 4. 15. Thesis Supervision/Guided: No. Experience in guiding Awarded research (in figures) 1. 2. 3. Ph.D. [Link]. PG/ PG Diploma
Amount Sanctioned Rs.
Period of Project
Year of Completion
Under submission (in figures)
In progress
Remarks
16. National/International Symposium/Workshops/Winter/Summer Schools organized by the applicant: Sl. Title Sponsors Duration Co-convener No. 1. 2. 3. 4. 17. Research publications (in ISBN/ISSN numbered Journals and Books) Sl. Publications No. 1. Books (as the only author) 2. Books (Coauthored with others) 3. Edited books (as the only editor) 4. Books edited with others 5. Refereed International Journals 6. Refereed National Journals 7. Publications in refereed conference proceedings 8. Publications in non-refereed conference proceedings 9. Other publications
Published (in Nos.)
Signature
of
the
Candidate
18. Conference presentations/attendance (Details to be attached separately) Sl. Details National No. (in Nos.) 1. Plenary Lectures 2. 3. 4. 5. Invited talks Contributed oral presentations Poster presentations Only attendance
International (in Nos.)
19. UGC Refresher Courses/Orientation Courses attended: 1. No. of Refresher courses attended 2. No. of Orientation courses attended
20. Experience in Extension Work : (Use separate sheets, if necessary)
21. Travel or study abroad Country visited From
Period
To
Purpose of visit
22. Knowledge of languages Languages Ability to speak
Read and Write
Speak, read and write
23. Any other fact(s) you would like to present for consideration in support of your candidature ;
(information regarding the qualifications, experience etc. desirable for the post prescribed may be indicated here). Use separate sheets, if necessary
Signature of the Candidate
24. Registration Fee Details (a) Amount of Demand Draft DD Number & Date (b) Drawn on (Drawers bank) with Code No.
: Rs. _______________________________________ : __________________________________________
(c) If remitted in account No.10000 at Canara Bank, GRI campus) Amount and Date of remittance : Rs._______________Date:___________________ (counterfoil should be attached) 25. Name and address of not less than two persons (not related by blood or marriage) to whom confidential reference could be made. They should be in a position to evaluate you for the suitability of the position you are seeking now. ( All of them should be familiar with your Academic /Professional work) 1 2 3
Phone: Email:
Phone: Email:
Phone: Email:
26. Character & Antecedents Report
: Remarks
Subject Have you ever been subject to any disciplinary action, as a student and/or as an employee. If so give full details Have you ever been dismissed/suspended from service/employment, if so please give full details Were you involved in any criminal case? If yes, give full details Is any criminal case pending against you in the court? If yes, give full details
Signature of the Candidate
27. List of enclosures 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
I hereby declare that the statements made above and information given in the application are true to the best of my knowledge and belief. At any stage if any of the above information furnished by me is found to be false or incorrect, suitable action may be taken against me. If selected, I promise to abide by the rules and regulations of the Gandhigram Rural InstituteDeemed University. Place: Date: Signature of the candidate
Endorsement of the present employer (if already employed)
Signature of the Employer
Office seal with date:
Name: Designation:
