INDIAN INSTITUTE OF TECHNOLOGY KHARAGPUR

/ APPLICATION FORM

.
Advt. No.:

Post applied for

R/05/2015 Dated July 16, 2015

1.

Candidates Name in full (in CAPITAL letters)

2.

Self attested
photograph

Fathers Name
3.

a) / Marital Status

b) / Gender

4.

a) / Permanent Address:

b) / Correspondence Address:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

/ Dist: _________________________________

/ Dist: _________________________________

/ State: ________________________________

/ State: ________________________________

/ PIN Code: __________________________

/ PIN Code: __________________________

./ Phone No.: ___________________________

./ Phone No.: ___________________________

- / E-mail: ______________________________

- / E-mail: ______________________________

5.

/ Date of Birth

( /
please enclose attested copy of certificate)

6.

?
Are you a citizen of India?

( , / If no, please provide the details)

7.

/ Category (GEN/SC/ST/OBC/PH/ES)
(SC/ST/OBC/PH/ES
/ please enclose attested copy of certificate in case of
SC/ST/OBC/PH/ES)

8.

If you are employed, please state the name and

address of present employer, present basic pay and
scale of pay / Pay Band & Grade Pay.

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9. / Details of educational qualifications: ( /

( ) / Please give particulars of all

examinations passed and degrees obtained commencing with the High School Leaving 10th standard / Matriculation
Examination. (Please attach true copies of certificates and mark sheets duly attested)).

/
..
Sl#

/
Examination/
Degree/
Diploma passed

/ /

Name of the Board /
University / Institution

Passing
Year

Percentage
of marks

Distinction /
Class /
Division

/ Subjects
( , ,
,
/ Please mention field of
specialization, honour, etc.,
where applicable)

10. /Details of employments:

( / Please give particulars of present and past

employments in chronological order, starting with the present one )

..
Sl#

/
Name of the
Organization /
Institution

Post held

Employment
/ From

/ To

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( / )

Employment
period

(in year/month)

Last /
Present
Basic pay

Pay scale /
Pay band &
grade pay

Nature of duty

11.

/ Additional Remarks:
( ,
, / Mention
special qualifications or experience, including that of computer knowledge, which have not been
included under the heads given above)

12.

/ Details of enclosures:

, ,

.
I hereby declare that I have carefully read and understood the instructions and particulars supplied to me and
that all the entries in this form are true to the best of my knowledge and belief.
/ Date :______________
_____________________________
/ Candidates Signature

/ To
, -III / Assistant Registrar, E-III

/ Indian Institute of Technology Kharagpur

- / Kharagpur 721302
/ West Bengal
/ India

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