APPENDIX A
Defence Institute of Advanced Technology
(A Deemed to be University u/s 3 of UGC Act 1956) Girinagar, Pune- 025
An Autonomous Organisation fully funded by Department of
Defence Research & Development, Ministry of Defence, GOI)
FOR OFFICE USE ONLY
APPL. NO.
PASTE HERE A SIGNED
COPY OF YOUR
RECENT PASS-PORT
SIZE PHOTOGRAPH
DATE:
Name of the post applied for: ___________________________________
Advt. No 04-NTS-2016
Date 19th September 2016
Demand Draft No. .. .
Date . for Rs ..
Issuing Bank & Branch .............
payable at:
Pune Branch:
IAT (02155)
Bank Name:
State Bank of India
GENERAL INFORMATION:
1.
(i)
Name in Full
: .
(ii)
if married, maiden name
2. Fathers/Husbands Name:....
3. Date of Birth
: Date..Month..Year....
(As recorded in Matriculation or equivalent certificate)
4. Age (as on the last date for receiving of application): years.months .days
5. Nationality
: .
6. Marital Status
: Married / Unmarried
7. Sex
: Male / Female
8. (a) Category
: ST/SC/OBC. If any other, specify
(b) Sub category
: PWD(OH/VH/HI)/Ex-Serviceman/Sports. If any other specify?
-29. PERMANENT ADDRESS:
.
.
.
10. ADDRESS FOR CORRESPONDENCE:
.
...
Email
..
Land-line Ph.: .. Mobile ....
11.
EDUCATIONAL QUALIFICATIONS (*) (from Matriculation onwards):
Examination
Board /
University
Year of
Passing
Marks
Obtained
Out of
% of
Marks
Matriculation
(10th)
Higher
Secondary /
Intermediate
(12th)
Diploma/
Bachelors
Degree
Any other
Bachelors
Degree
Masters
Degree
M. Phil./ Ph. D.
Technical
Qualifications
(if any)
Computer
Qualifications
Any other
Qualification
(if any)
(Note : (*) Please attach separate sheets if the space is insufficient)
Class/
Grade
Subject(s)
-312.
TEACHING/TECHNICAL/PROFESSIONAL EXPERIENCE (Starting from the latest): (*)(#)
Designation
Note:
(*)
(#)
Name of the
Organization/
in case of nonGovt. pl
specify.
Basic pay (Pay in
pay band+ grade
pay)/Pay Band/if
any other scale, pl
specify clearly.
Nature of
Appointment
Regular/Permane
nt/Temp./on
contract/ Adhoc
From
Period of Service
To
Period
Attach separate sheets if the space is insufficient.
Attach Service Certificates indicating the period of employment and breakup of
emoluments drawn.
13. ADDITIONAL INFORMATION, IF ANY:
14.
I hereby declare that all entries made by me in this application are true, complete and correct
to the best of my knowledge and belief. I understand that in the event of any information being found
false, incomplete or incorrect, my candidature/appointment is liable to be cancelled/terminated. I have
enclosed attested copies of the supporting documents in respect of Sr. No. 3, 8, 11 and 12 above.
Place..
Date..
(Encl: As above)
Signature of the Applicant
-4ENDORSEMENT OF THE EMPLOYER
Ref. No
Date
1. The application of ___________________________________ is hereby forwarded with the
remarks that we have no objection to his/her application being considered.
2. Certified that the information given by the applicant in this application form has been
checked/verified and found to be correct with reference to his/her service records.
3. Applicable in case of deputation: Attested copies of the applicants confidential reports for the
preceding five years along-with Vigilance Clearance/Integrity Certificates.
Signature of the forwarding Officer
(With office seal)
(The endorsement on this page is to be signed and forwarded by the Head of the Department/Employer in the
case of candidates, in service whether in permanent or temporary capacity failing which the application is liable
to be rejected).
__________________________________________________________________________
CHECK LIST
1.
2.
3.
4.
5.
6.
7.
Have you signed on your Application?
:
(Tick Yes or No)
Have you attached the Self - Attested Copies of all the :
Certificates/Testimonials?
(Tick Yes or No)
Have you enclosed Self Attested copy of proof of Age? :
(Tick Yes or No)
Have you enclosed requisite Demand Draft, if applicable :
(Tick Yes or No)
Have you enclosed Self-Attested Copy of SC/ST/
:
OBC/EX-Serviceman/PWD Certificate, as applicable?
(Tick Yes or No)
Have you pasted your photograph on your application?
:
(Tick Yes or No)
If you are employed, have you forwarded your application :
through proper channel?
(Tick Yes or No)
**************
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
