INDIAN SCHOOL OF MINES

DHANBAD-826004
JHARKHAND,INDIA
(Please Fill in BLOCK LETTERS)
Advertisement No.
Post Applied for
epartment
Ban! raft No." ate
#.Name in F$ll (First S$rname)
(Please ti%!)
&. Address' Present
Permanent
FA(
E)mail
Telep*one + ,o-ile Offi%e' Residen%e'
.. ate of Birt* /. Nationalit0'
a0 ,ont*

1ear
2. Present Emplo0ment
esi3nation
Or3ani4ation
ate of 5oinin3
S%ale of Pa0 (Rs).
Basi% Pa0 (Rs.)
Total Emol$ments
(Per mont*)(Rs.)
6. Basi% Pa0 e7pe%ted (Rs.) 8888888888888888888888888888888888888888888888
Affi7 *ere
re%ent
passport si4e
p*oto3rap*
,arried Sin3le ,ale Female
Applicatio !o" Fac#lt$%
A&'ii(t"ati)* +o(itio
Applicatio !o" Fac#lt$%
A&'ii(t"ati)* +o(itio
9. (a) Ti%!)mar! t*e appropriate -o7 if 0o$ -elon3 to reserved %ate3or0
(Please atta%* ne%essar0 %aste %ertifi%ate iss$ed -0 an a$t*ori4ed offi%er onl0.)
SC ST OBC P:
;. Total 0ears of t*e e7perien%e after attainin3 essential <$alifi%ation
=. Areas of Spe%iali4ation
#>. C$rrent Areas of Resear%*'

(Onl0 for a%ademi% positions)
##. A%ademi% Re%ord startin3 ?it* se%ondar0 ed$%ation (Please atta%* (ero7 %opies of e3ree Certifi%ate)
E7amination Bran%*+
Spe%iali4ation
Colle3e+@niversit0
+Anstit$te
1ear Per%enta3e
+Brade
Class+
ivision
#&. Emplo0ment' (parti%$lar of 0o$r past position (s))
Emplo0er Position *eld ate of Coinin3 ate of
Leavin3
Pa0 ?it* S%ale
of pa0
#..:ave 0o$ ever -een dis%*ar3ed+s$spended d$rin3 0o$r earlier emplo0mentD
Af 0esE state reasons'
#/ Spe%ial A?ards+:ono$rs re%eivedE if an0'
1ear Name of A?ard+:ono$r Name of Or3anisation
#2 ,em-ers*ip of Professional Bodies'
Name of t*e Bod0 Stat$s of ,em-ers*ip' Life+Ann$al
#6 Please mention -elo? -est five resear%* p$-li%ations and atta%* separate list of all
p$-li%ations'
Sl.No 1ear Title of P$-li%ation Name of Co$rnal
#.
&.
..
/.
2.
#9Names and addresses of three Referees (at least one of t*em s*o$ld -e familiar ?it* 0o$r re%ent ?or!s)
(#) (&) (.)
Name
O%%$pation or
position
Address
Fa7
E)mail
P*one No.
#; Statement of O-5e%tives (to -e filled $p in CandidateFs o?n *and ?ritin3)
a) Please indi%ate as to ?*0 0o$ ?is* to 5oin AS,E *an-ad.
-) :o? in 0o$r opinion do 0o$ meet t*e 5o- re<$irements as advertisedD
%) A s*ort para3rap* a-o$t t*e resear%* +tea%*in3+development pro5e%ts 0o$ ?o$ld
li!e to $nderta!e and t*e %o$rses t*at 0o$ ?o$ld li!e to *andle at @B and PB
levels.

#= A *ere-0 de%lare t*at A *ave %aref$ll0 read and $nderstood t*e instr$%tions and
parti%$lars s$pplied to meE and t*at all entries in t*is form as ?ell as atta%*ed s*eets
are tr$e to t*e -est of m0 !no?led3e and -elief.
T*ere are atta%*ed s*eets alon3 ?it* t*is form.
ate'
Pla%e'
(Signature of Applicant)
Not*, -(* (*pa"at* (.**t i! *c*((a"$ !o" a$ o! t.* a/o)* it*'(0
Indian School of Mines, Dhanbad
(All particulars to be filled by the applicant)
(Grite f$ll mailin3 address on reverse and affi7 ne%essar0 posta3e stamps)
Name (in BLOCK LETTERS)8888888888888888888888888888888888888
Post Applied for 88888888888888888888888888888888888888
epartment 88888888888888888888888888888888888888
88888888888888888888888888888888888888888888888888888888888888888888888
8
(for office use only)
Re%eived on 88888888888888 88888888888888888888888
Si3nat$re of Re%eiver
ACKNOWLEDGEMENT