CENTRAL INSTITUTE OF PERTOCHEMICALS ENGINEERING &

TECHNOLOGY (CIPET)
(An Autonomous Body under the Ministry of Chemicals & Fertilizers,
Govt. of India)
Advt. No. CIPET/HO-AI/02/2023 Date: 12.04.2023

Recruitment of Supervisory and Non-Supervisory Posts (Technical / Non-Technical)

Note. i) Please read the attached information regarding last date of submission of duly
completed application form, Essential Qualification & Experience and Rules &
Regulations before filling the application form.
Paste
ii) Please tick ( ) whichever is applicable in the box.
passport
1. Post Applied for size
photograph
2. Full Name
(in block letters)

3. Date of Birth Blood Group

4. Community
(SC/ST/OBC/GEN)
(Enclose attested copy of certicate)

5. Whether Economically Weaker Section (EWSs) Yes No

(Enclose attested copy of certicate)

6. Whether Physically Challenged Yes No

If yes, state % of disability

(certificate to be enclosed)

7. Whether Ex-servicemen Yes No

8. Gender Male Female Others

9. Marital status Married Single Others

10. Nationality Religion

11. Mother tongue

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12. (a) Name and Address of Parents

(b) Name of Spouse (if applicable)

(c) If spouse is employed,

Give employment details/place

13. Postal address for correspondence

with pincode

Telephone Land Line Mobile

E-mail

Nearest Relative’s Mobile Number: a)

b)

14. Permanent Address with pincode

Place of Upbringing / Hometown:

15. Postal address of the present employer

with pincode

WEBSITE:

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 16. Were you at any time declared medically unfit; asked to submit your resignation; discharged
or dismissed from Govt./Semi-Govt./Autonomous Body or Private Service?

If yes, give details in a separate sheet.

17. Have you ever faced any Vigilance Enquiry or enquiry by anti-corruption bureau/Central
Bureau of Investigation or any other Investigative Organization or police
investigation/enquiry in connection with FIR/ charge sheet lodged ?.

Yes No

If Yes: Please indicate in brief, the details of the Vigilance Enquiry and outcome thereof in
separate page

18. Academic Qualifications:

(Please attach the self attested photocopies of Certifictes/Mark Sheets)

Give particulars in a chronological order starting with SSLC (Xth Std) School Certificate

Duration
Pass
Name of % of of Course
Mode of study Division
Course / Marks (whether
Sl. Subject/ (Full Time / (Ist or Year of
Degree / / 1 yr. or 2
No. Specialization Part time / IInd or Passing
University / CGPA yrs. or 3
Correspondence) IIIrd)
Board yrs.
Class
Course)

Enclose separate sheet(s), if required.

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19. Professional Qualification (e.g. Professional Training, Courses, Workshops etc.)
(Enclose separate sheet(s), if required.)

20. Employment details: (Details in chronological order, starting with present employment
upto the first employment

Pay Period of Place /

Name & Address Position Nature
Sl. Scale & Employment state of
of Organization / held / of
No. Gross (Month/Year) employ
Employer Designation Duties
Salary ment
From To

Enclose separate sheet(s), if required.

NB: If self-employed, please indicate average monthly income

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21. If you claim Experience, please furnish details,

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22. Extra - Curricular activities, if any:

 Participation in N.S.S. activities :

 Participation in University - Industry Interaction :

 Participation in Sports activities at university / State level :

 Participation in any other activities such as Rector of the Hostel , etc :

 Sports Winners at Zonal, Inter-Zonal state and National level Tournaments:

Any other work :

23. Current Membership of Professional Bodies and Awards / Scholarships received (if any):

a) Membership of Professional Bodies (National / International Level)

b) Other Achievements (National / International)

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24. Knowledge of foreign languages

25. Overseas assignment / training

26. Reference

Responsible persons not related to the applicant but closely acquainted with the applicant

Name and Designation Address

Phone:

Email:

Phone:

Email:

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27. Last drwan pay details (Last pay Slip to be enclosed)

Basic Rs Scale of Pay:

Garde Pay (if any) Rs

DA Rs

H.R.A. Rs

Any other pay Rs

Total Gross Slary Rs

28. Notice period / No. of days likely to be availed for relieving from present employer, on
selection:

29. (a).Details of relatives working at CIPET, if any :

(b). Any other information you may like to furnish to CIPET:

30. Deatails of GATE Score (Attach copy of GATE Score Card), applicable only for Asst. Technical
Officer

Sl.No Year Discipline Score

31. Social / Political / Religious Affiliations of the Candidate if any, Mention the name and clear
details about the affiliations:

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 DECLARATION

I declare that the entries made in the Application Form are correct and true to the best of my
knowledge and nothing has been either concealed or misrepresented by me. In case of any
misrepresentation, I understand that employment if any gained, is liable for termination.

Place: Signature

Date:

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 Forwarding of Application through proper channel:
(To be filled in by the forwarding authority).

(Applicable for Candidates from Central/State Govt./PSU/Autonomous/Quazi-Govt. only)

Forwarded to Central Institute of Petrochemicals Engineering & Technology (CIPET)

The applicant is working in this Office / Organization / Institute / University as

________________________________ since _______________________and is still in service. We have No
Objection to his/her candidature being considered for the post he / she is applying.

Place:
Date:

Signature:__________________________

(Name & Designation of the Forwarding Authority with seal)

N.B.: 1). Use separate sheets wherever necessary while filling application form above.

2). All entries in this application form shall be neatly typed/Hand Written.

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