Indian Institute of Technology Indore

Application for Academic Appointment

Date of Application: _________________________________
Post Applied for: _________________________________
Discipline: _________________________________
1. Name:
First Name Last Name Middle Name
2. Personal Details:
a) Date of Birth: __________________
(dd/mm/yyyy)
b) Ae: ___________________
c) !ender: ________________
d) Marital "tat#s: ________________
e) Nationalit$: ________________
(in years)
%. &a) 'ontact Address:
__________________________________
__________________________________
__________________________________
&b) Permanent Address:
__________________________________
__________________________________
__________________________________
(. 'ontact Details (with STD/ISD code):
a. Phone &)ffice): _______________
b. Phone &*es): _________________
c. Mobile: _________________
d. Fa+: __________________________
e. ,-mail .D:
______________________________
/. Academic record startin 0ith school lea1in e+am:
&Please attach photocopies of transcripts2 mar3 sheets2 rade card and certificates for all $o#r
derees):
"peciali4ation
2 Discipline
'ollee25ni1ersit$2.nstit#te
6ear of
7oinin
6ear of
lea1in
Percentae
2 '!PA
Afx a
passport size
color
photograph
8. Areas of speciali4ation: ____________________________________________________
_______________________________________________________________________
9. '#rrent area of research: ___________________________________________________
________________________________________________________________________
:. Present emplo$ment:
;. Basic Pa$ e+pected at ..<. as per ad1ertisement= *s. ___________________________
1>. .nformation of three *eferees:
&Names and contact details of referees 0ho 0o#ld be 0illin to 0rite in s#pport of $o#r application):
*eferee 1 *eferee 2 *eferee %
Name
Desination
)rani4ation2
.nstit#te
Address Line 1
Address Line 2
Address Line %
<elephone
,-mail i.d.
11. Please tic3 the appropriate bo+:
&Please attach a certificate from the a#thorit$ prescribed #nder o1ernment r#les for "'2"<2)B')
12. . hereb$ declare that . ha1e caref#ll$ read and #nderstood the instr#ctions and partic#lars s#pplied to
me= and that the entries in this form as 0ell as in attached sheets are tr#e to the best of m$ 3no0lede
and belief.
<here are ___________ sheets attached alon 0ith this form.
Date:
______________________________
Place: (Signature of Applicant)
Desination
)rani4ation
Date of 7oinin &dd2mm2$$$$)
"cale of Pa$ in *s.
Pa$ in *s.
<otal ,mol#ments &per month) in *s.

!eneral "' "< )B'

PROVIDE THE FOLLOI!" I!FOR#ATIO! ITH THE APPLI$ATIO!: &.ndicate ?N.L? if
re@#iredA DO !OT omit2delete the follo0in points. 6o#r application ma$ not be processed in the
absence2incompleteness of the follo0in information)
Note:
i. For items BaC thro#hBsC= #se separate sheet for each s#b-headin in the format indicated.
ii.All anne+#re sho#ld be consec#ti1el$ arraned and m#st bear $o#r name.
a) List of p#blications:
List those P5BL."D,D= A'',P<,D= and .N P*,PA*A<.)N separatel$
a. Papers in refereed 7o#rnals &Please also incl#de the 7o#rnal impact factor)
b. Papers in conference proceedins
c. Papers presented in conferences b#t not p#blished
d. Boo3s2'hapters in boo3s
Please enclose reprints of ma+im#m of three papers 0hich in $o#r 7#dment are $o#r best.
b) ,mplo$ment histor$:
c)
<
e
achin ,+perience= 'o#rses2Laboratories:
&.ndicate an$ special 0or3 done to0ards de1elopin ne0 co#rse or laboratories)
"l. No. <itle of co#rse
ta#ht
Postrad#ate2
5nderrad#ate
"ole instr#ctor or 0ith
others
6ear
d) *esearch ,+perience: &incl#din Post doctoral)
e) Post !rad#ate <hesis "#per1ision:
"l. No. Position )rani4ation2.nstit#tion
Date of
7oinin
Date of
lea1in
D#ration
"l. No. Position .nstit#te "#per1isor <opic Date of
Eoinin
Date of
Lea1in
D#ration
"l. No. Name of st#dent2 research
scholar
<itle of
<hesis
Doctorate2
MasterCs
6ear of
'ompletion
'o-#ide &.f
an$)
f) "ponsored Pro7ects 5nderta3en:
)
'ons#ltanc$ For3 Done:
h) .nd#strial ,+perience .nteraction:
i) Professional <rainin *ecei1ed:
7)
M
embership of Professional Bodies2)rani4ations:
3) .mportant 'onferences2"eminars Attended:
l) 'ontrib#tions &teachin) to 'ontin#in ,d#cation Prorams
m) "hort-term 'o#rse2For3shop2"eminars etc. orani4ed
n) )ther academic and corporate acti1ities
o) A0ards and reconitions
"l. No. "ponsorin Aenc$ <itle of
Pro7ect
Amo#nt of
rant
Period 'o-in1estiator
&.f an$)
"l. No. )rani4ation Nat#re of For3 Period
"l. No. Name of <rainin
)rani4ation 0here trainin 0as
recei1ed
6ear D#ration
"l. No. Name of the Professional Bod$ Membership "tat#s
&Life2Ann#al)
"l. No. 'onference2"eminar <itle of paper read &if an$) 6ear
"l. No. )rani4ation <itle of
Pro7ect
Amo#nt of
rant
Period 'o-in1estiator
&.f an$)
p) Please list the t$pe of #nderrad#ate co#rses that $o# 0ill li3e to de1elop and2or teach at ..< .ndore
&attention is dra0n to o#r 5! s$llabi posted at http:22000.iiti.ac.in2docs2do0nloads2c#rric#lam2..<-
.ndore_5!-'o#rses-"t#dies_E#l$2>1>.pdf).
6o# ma$ additionall$ incl#de the postrad#ate co#rses that $o# ma$ li3e to de1elop at ..< .ndore.
@) Please attach a brief statement &less than 2 paes) on $o#r immediate short-term research plans &2-%
$ear time frame). Additionall$= please also incl#de the research facilities &e@#ipment= space= f#nds=
manpo0er) that $o# 0ill need for $o#r research 0or3.
r) Please 0rite briefl$ 0h$ $o# 0ish to be considered for a fac#lt$ position at ..<. and ho0 do $o#r
lon-term career ob7ecti1es tie in 0ith a position at ..<.G Briefl$= also 0rite abo#t ho0 $o# propose to
contrib#te to ..<.= and ho0 the .nstit#te can help for $o#r best possible professional ro0th
&%>> 0ords).
s) An$ other rele1ant information $o# ma$ li3e to f#rnish