Central Institute of Plastics Engineering & Technology Signed
(Ministry of Chemicals & Fertilizers, Govt. of India) Passport
size colour
photo
Application Form for the post of Non-Technical Positions
1. Post applied for ______________________________________________
2. Full Name (including Surname) ________________________________________________
(in block letters)
3. Date of Birth / Place of Upbringing / Blood Group_________________________________________
4. Community i.e.
SC/ST/BC/MBC/OBC/GEN ________________________________________________
5. Whether Physically Challenged:
(i) Yes / No. ________________________________________________
(ii) If Yes whether OH/HH/VH
(Orthopedically/Hearing/Visually) _________________________________________________
6. Sex Male / Female (Strike off whatever is not relevant)
7. Marital Status Married / Unmarried / Divorced / Widow/er (Strike off
whichever is not relevant)
8. (a). Nationality /Religion ___________________________________________
(b). Mother Tongue ----------------------------------------------------------------------
9. (a) Mother's Name and Address _______________________________________________
(b) Father's Name and Address _______________________________________________
(c) Name of Spouse _______________________________________________
(d) If Spouse employed, Name of firm
& Place of Employment _______________________________________________
(e) No. of Children / their age / Study /
Employment Details _______________________________________________
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(Column No.10 shall be typed only.)
10. (a)
Postal Address for correspondence _______________________________________________
(any change of address should be _______________________________________________
communicated at once to the Institute) _______________________________________________
Pin Code _______________________________________
(b)
Postal Address of the Present Employer _______________________________________________
_______________________________________________
________________________________________________
Pin Code _______________________________________
Telephone Nos.
(Office) __________________________________ (Mobile) ______________________________
E.mail: Website _______________________________
(c) (Res.) 1). _________________________ 2).___________________________
(Mob.) 1). _________________________ 2).____________________________
Your Nearest Relative’s Mobile No. 1). ________________________
2)._________________________
Email :
(d)
Permanent Address _______________________________________________
(Mention Tehsil, District and State _______________________________________________
you belong to) _______________________________________________
11. 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.
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12. Have you ever –faced any Vigilance Enquiry or enquiry by anti-corruption bureau/Central Bureau
of Investigation or any other Investigative Organization: Yes / No
If Yes: Please indicate in brief, the details of the Vigilance Enquiry and outcome thereof (If exonerated, a
copy of the order passed by the competent authority may be furnished)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
13. Academic Qualifications: (1) Please attach Xerox copies of certificates & mark sheets
including Date of Birth.
Give particulars in a chronological order starting with High School Certificate to Post Graduation
Name of
Whether Full Time / % of Marks
Course / Whether course passed /
Subject/ Part time / Period of Study
S.No. Degree / Not passed /
Specialization Correspondence From - To
University / Year of Passing
Course
Board
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14. Employment details: (Give particulars in descending chronological order starting with the present
post).
Place / State Period of Employment
Pay Scale & Gross
Employer Post held of (Month/Year)
S.N. Salary
Employment
From To
NB: If Self Employed, please indicate average monthly income.
15. Area of specialization (to be filled in on the basis of Academic Qualification and experience relevant to
the post applied):
Main Field Specialization Super-Specialization
16. If you claim experience on the applied side: Industrial or else with expertise relevant to job applied,
please give a brief account of duties performed / being performed by you”
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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17. Current Membership of Professional Bodies and Awards / Prize won / Scholarships received(if any) :
a) National Level International Level
1. ________________________ ____________________________
2. ________________________ ____________________________
b) National Awards International Awards
(Indicate Year)
1. _______________________ ____________________________
2. ________________________ ____________________________
18. Outline few project proposals that you would like to submit to various funding agency on joining
CIPET. (Annexure – I) (A brief write up may be given).
Specialized area you would like to strengthen on joining CIPET. (Annexure – II) (A brief write up
may be given).
Why you should be considered for the positions applied. (Annexure – III) (A brief write up may be
given).
19. Reference
Responsible persons, not related to the applicant but closely acquainted with applicants academic and
professional work.
Name and Designation Address
Phone: Fax:
Email:
Phone: Fax:
Email:
20. Last drawn pay details (Salary Certificate to be attached)
Basic Pay Rs. Scale of Pay:
D.A./I.D.A. Rs. In case of Govt. / Quazi-govt. firms
State whether scale of pay above is
H.R.A. Rs. Pre-revised / Revised scale of Pay :
CCA Rs.
Other Allowances Rs.
Total Gross Salary Rs.
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21. Notice period / No. of days likely to be availed for relieve from parent organization on selection:
22. a). Details of relatives working at CIPET, if any :
b). Any other information you may like to furnish to CIPET:
23. Social / Political / Religious Affiliations of the Candidate if any, Mention the name and clear details
about the affiliations :
24. For Re-appointment (applicable for Ex-Employees).
(a)
Employment details at the time of Resignation from CIPET.
i
) Date of Resignation
i
i Designation & Grade held
)
i
i Department & Division
i
)
i
v Last scale of pay drawn at
) CIPET.
[
(b)
Employment details at the time of joining CIPET.
i) Date of joining of CIPET
ii Designation & Grade to
) which appointed.
ii Department & Division
i)
i Scale of pay drawn during
v initial posting at CIPET.
)
v PF No. at CIPET.
)
N. B. : (Use separate sheets wherever necessary while filling application form above)
25. Copies of documents enclosed:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
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Declaration
I Declare that the Entries made in the Columns of this proforma 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 :
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)
Date: ________
Forwarded to the Director General, Central Institute of Plastics Engineering & Technology (CIPET),
Corporate Office, Guindy, Chennai. The applicant has been 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:
Signature ________________
Designation ______________
(With Seal)
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