You are on page 1of 9

~~~'lc

Chlllf("fll ~,

ftlf

~-\W1T

-;:t, 07759-659874,

3ffq) ~CMI("fIGft, q)~'<~1(Uo l"fo)


m,1fJ11 $l~1\{61, -q)-.- fu:rcfi, ~
- 495 683

099814-43708,

094241-44099,

Web site :- www.itkorba.com


~

3TTt:tr:~./~.

~.tr, ~
~,

'H1'1OiI11e18NT 'IOiillR>lC1~ttl<4\c
~

~c'lCf~If.1CM ~.),

~c'lCf~If.1CM ~./4cfif.1ChC1

~./~c'lFcr~ChC1
3l~R:c
~,/~)

05:00

~,),

08/08/2015

(~1J11f.1l1Rll liglfc1t1IC1l1) #

~c'lCf~If.1CM ~,/~cfif.1Ch(1),

(fufc'rc;r
~

~c'lCf~If.1CM ~,/4cfif.1ChC1

3ITQ) 2:CHIC1IIJ11.~

1~c'lFcr~ChC1 ~
~,

098266-12408

cmw, ~

1 2015 11533

(ChA<{c'lO~

(~c'lFcr~ChC1 ~

098939-05053,

e-mail:korbait@rediffmail.com

~.I

ChA<{c'lO~

~tfl~~c

~,I

2:CM1~I<F1 (fufc'rc;r ~,IChA<{c'lO

cfi

fTcITf f.1l1~d

if\Jl acp cBcrC1' cBcrC1' ~l \S41 fC 1

'10

f~1fcJ

~c'lFcr~ChC1

-gg ~

-qc;T cBT ~

~,

10.09.2015

-cfR:c; 1 CfilR 11'10 cfi +m:lfli' ~ ~

~~~~I

-qc;T cBT ~,

fc1$11 q '1 CBT ~

fcl'cRur, <W<mT, f.1<Tli'1~

~iHil~C: www.itkorba.com CBT 3lClC1'ICh'1qR I

~ ~

Lf'3I'

cfi >fRi)q -gg ~

Lf'3I'

Cf)llIf("lli

~F*t1~1c3ff"cp

~,

ftlf

cmw-\3XllT

e:CMIC1I\J1l, Cf>lxfJIl (t90 "lTo)

xts,"!f11l liP I'< 81, "tfT.-

funfi,

cmw

- 495 683

1fiT;:r 1'. 07759-659874, 099814-43708, 094241-44099, 098939-05053, 098266-12408


Web site :- www.itkorba.com
e-mail:korbait@rediffmail.com

~/3T&.iT:$./~./20151)6~

~,

3T&.it.

(Cf)~cx

(~~fc}~Cf)C1 ~
~

GRT fjillR1d

fllf1I~t)
~

~~~If.1Cffl

~.),

~~4'~If.1Cffl ~./~cfif.1Cf)C1

~~FcltCf)C1 ~

cBT ~

~~~If.1Cffl

~-4

cBT

fd"fu

10.09.2015

I Cljfc}(1lld Xi)q

~
(~

~-&'I<1c

xf ~

cf>

31~t?;C

(ffrfclc;r ~.ICf)~cx

WJ

WIT ~
~

3l]l{i ~CMIC11\J1l cvlffi

cf> ;wr ~

51,

"Itil~"Ic

cBT

f1f[1l~d

>rriIl1f,

~-&'I<1c

cf>

-m lR

cj\J1"ICQd~/~

~./~~fc}~Cf)C1
~

Cf(1)

~.I

% I trc:T
f.mffuf

~
\OlffiR1~

cf>

\ii'1\iilffi
"f1C;rr.=r
~

cf> ~
~

~/~

2001- (~

crt cf> ~

cfr

3001-

"fit 1lT?f) \J1T fcn ~,

~l1GT

<nT <fl11

qft

(2)

(1)

*~

(QRtf.1~Rh1 I~

(~d'1S11'i Xii. 37400 -

**~

(~

cf>

(~d'1S1I'1 Xii. 374001.

Cf)~cx~~~.

2.

~~fc}~Cf)C1~

3.

~ cfif.1Cf)C1

-msm
(3)
01

lflUllf ~)

67000, 3l.~.-q. Xii. 10000 ~

1TIff 1 QRtf.1~Rh1 I~

cf> lflUllf

*~
3TnJ~
(4)

Xii. 3000 )
58 Cflf

~)

67000, 3l.~.-q. 10000)


01
~~~If.1Cffl

ffT~

31fq) ~Cf'11C11\J1lcvlffi,

10109/2015

em ~

31jfJFld

"fl11ffi 3iiC1~~Cf)>fl1TUT-~

cvlffi - 495683
~

~./~cfif.1Cf)C1),

~CM~~I~'1 (ffrfclc;r ~.ICf)~cx

"f1l<l 05:00 ~

tIT.- ~,

\JfTfu ~

~~~If.1Cffl

(~\J1"If.1~Rll S1glfc1wC1~)

cf> fufd trc:T %g ~


~ ~
~
crfi1Tc1 d IR1Cf)I 1 ~ 2 "B eft ~ % I ~

\ii1'1Cf)I~ ~

X1T~ xl~~~CQd

"fit 1lT?f), 31jfJFld

\iil '1Cf)I~ ~

"B, ~

cvlffi-\1X1lT R1f xts,lJTll WTW,

xf ~

1 ~cfif.1Cf)C1~.),

~.

3l]l{i ~CM1C11~, ~

~./~~fc}~Cf)C1

~./~),

R fc}(1<ficBT ~

mw:r "B,

~)<~c

01
01

~~

(I)

04

.~

~'ti~~~c

~1,()'(1'(

(~(F1lil'1 ~.374001.

tl)

'ij(ff ~ ~

50 q1f

67000, 31.~.-q. ~. 9000)

~~Fcr~cpC'l ~

~~Cf~I~Cffl

01

~.

<WI (II)
(M

~1,()'(1'(

tl)

'ij(ff ~ ~

(~C'1'1lil'1 ~.15600-39200,

3L~.t

01
21

04

2.

cp~c'<~~~.

03

3.

~~~I~Cffl

4.

~ cfl~cpC'l

02

5.

01

~~~I~Cffl

eCM1~1~'1 ~

(~C1"llil'1 ~.5200-20200,

tl)

-q ~.

01

'ij(ff ~ ~

<WI (III)

11

<fl1T (I) +(1I)

17

~ 'R11fclC'1l:fGT ~

3Wl~

2800)

1. fufch;r ~.

03

2.

cp~c'<~~~.

01

3.

~~~I~Cffl

4.

~cfl~cpC'l

30

q1f

~. 6000)

1. fufch;r ~.

tl

~~Cf~I~Cffl

18

01

tl

35 Cfff

02

<IT1T

07

&ii5ct1q10f ~:1.

*~

(~R'lPl9)Fcffi/~

l'lR'l~~FcrC1/~
liglFc1tllC'llj'j
\JfICf

# cm<fm

liglFc1WC'lll

q5

# cm<fm

fcm)

l'lR'I~ ~FcrC1I~

\JfICf

&m ~

fct.fct ~

tl ~

lj~lllC'111:TRt~

~\Jf\~llRll

fcm)

'ij(ff

I~

tl

IITIII ITfNIT, ~/~

lfIUIl1

~~

lilq~o\S'i

AICTE

q5 ~

tl)
&m ~~

lj'PllC'111:TRt~/C!'til~C!c

fct.fct. ~

~\Jf\~llRll

tl ~

%I
ctT ~

mT -qan ctT wl1fcl

~WY

TfN IT, ~/~

lilq~O\S'j ~

AICTE

(~R'lPl9)FcrC11M

l'lR'lf.1~FcrC1/~

2.

tl IIT/IIl

lfIUIl1

%I

**~

tl)

~ ~

tl ~

3.

l'lR'I~~FcrC1 I~

4.

wx=R &m l'lR'IPI~FcrC1I ~

3Wl ~

\JfT ~

I cwf

ctT 6Trft, \i'1T~

03 ~

q5

# cnW ~~ ;fflT 6PTI I


q5 ~'tf # \JfRt 3R:l ~ I -mf

~~

cg~1C'lC'11
1"Ga1c1T

C1Tl1

~~p

3lltlR 'R

~:-

1.

f.1mfur XTfu cpr ~

cfi xw:r

%1 ~

fu<:rr vrr ~
cfi ~

;wr ~

3.

4.

"fC1<l cpr 1lill fffisrr cffi:c-cmt

1f?r

5.

N<rr

;wr

"ct"m ~

lTG" cpr

\JlT ~

~lIfl<#l4 /f.1cit

-:) -gT ~

7.

1f?r ~

cBT ~

8.

9.

lRT cBT ~

l'!"!ilRi~e

cR' 3R1m

xf ~

vrr ~
~

~
~~

% J1~

(~c'lFcl'~4JC'l ~

"ffif

~./

x=i'+lq

xf \J11'i4JI~ ~

CR) ~

~c'l~If.1Cf'!i

%1

cnW ~

"ffl1ll{1

cBT vrr ~

New

~.)

% 1 J1(i: J1Cfm ~

\3&4lGClI"!

~c'lCf~IPiCRi ~./~cf5Pi4JC'l

3lRi"!-2e

~
~./~)

it. CBTffi "!ilfll~el

~.).

(fufcrc;r ~./

4JA<Ic"!

lTG" lR Pig;Fcl'ct ~

'(9\\11fPIi!> ct4J'-I'I<#I fua=rr (fua:rur

Delhi,

fctlwT GRT

~c'lCf~IPiCRi ~./~cf5Pi4JC'l

AICTE,

fu<:rr ~I

~c'lFcl'~4JC'l ~

f.1w1 2014 "ct"m ~.

li6IFcl1lC'l4) ~

cR'1

cR'1

\J1ClI~GI~ \3H"j'IGClI,,!cBT ~

(4JA<Ic"! ~

~./~c'lFcl'~4JC'l

cBT XTfu ~

cfi ~

~. ~

wmf f.1w1 ~

GRT "\JlRt

~~Pi4Rll

~-f.'rtm cpr

tITC'1""'i"

~I

11. ctlR14J1

2 cfi Fcl$1lfClct ~

eCM1~14'i

% 1 x:la1l1~

12. \3ullGClI"!
~

"!>l11:(f

cpr

<:ffi '!jf.1~ilct

fcl:R:Tr ~

Xii1:f

m-q-

cfi ~

/~

xf

3icPT

~ ~

l1Rl ~

31'R:l~

GRT wm)

lR -gT ~

fcn ~

-:) ~

cBT vrr ~

3icPT

cnT xilijc>=ll
3icPT

G11 C!\J1 cBT fl ,4 !>lffi R1 fCl ~

3ffi ~
~

3icPT cBT <fOT'iT cBT ~

liT?[ xf tr \3ullGClI"! Pig;Fcl'ct ~

it. CBTffi Xilfll ~ el cpr 6Trrr 1

-:) "!>l11:(f ~.

\3 Afl GCli"! "fC1<l cR' 1 ~


1"]()

~
~

fu<:rr vrr ~

"GTClT~

1f?r

CR ~

-B ~

3icPT ~

~
cpr

!>lllQiCf)'i -B 4RClmct CR.

"c#I" <fOT'iT

WTT<11 3R1m

cfi ~
"!>l11:(f ~.

3fcn

ciTfm; 3R1 >fI1TUT ~

"'i"fcn ~

%1
~

1"]()

cpr ~

'(9\\11WIi!> ~

Cf>X'iT~
GRT ~

cpr ~

1"]() ~.

lRT lR Pig;Fcl'ct cfi ~

>fI1TUT 1f?r ~

CR ~

Fcl~ ClFcl:IIC'l4 GRT "\JlRt fcl:i<)

15. ~

3R1m

fu<:rr vrr ~
lR

cBT fGjl:ilGI~ ~

<:IT~

31PiCl14ct: ~

10. >IT'EIT<f.~

fu<:rr

~.

cfi ~

CR ~

cfi xw:r ~

/fcr"r:m ~

cBT xfcrr -:) ~ -q- Pi 41 CffiI cpr 3l'i14fct1 >fI1TUT-1f?r (No Objection

"fix~

-:) ~

fcl:i<) 1"]()

lTG" cpr ~

cR' 1

cfi x-rTl2l
/x-rT~

6.

14.

1f?r

cR' 1

1 "fC1<l cpr 1lill fffisrr 02 R1 q; Iq; I (>ffi1 R1 q; Iq; I Xii. 40 / - cpr ~

Certificate) ~

13.

fcr"r:m ~

cfi xw:r 3@rcrr<f Xii1:f xf ~

G1IC!\111 cBT fk41fClct '(9141!>lffi41 ~

%1

cfi WR

~ ~

"ct"m G11 C!\111cBT fl ,4 IfClct '(914l!>lffi41 cfi 3l11TCf -:) ~

>m<Jq -:) ~

2.

1"]()

cBT fl,4lfClct

!>lffiR1fCl4'i cfi 3llUlX

fclcRur cfi ~

1 il4'114"!ict

Pig;Fcl'ct cpr ~

~.

16. ~

f.1gFcR1 ~

3Wf1T ~

31f.1cn<:l

*
W-en

cRtlffi/x=rr~

N<rr.

ftrn

I 3f~tMTI

m '4T ~

c#t ~

'4T >lCflR

LR ~

I ll5Fr

\3 ~ Rsl d fl16l1 ~ C'l ~

fuarCfl"

19.

20.

mm.

21.

'4T ~

xi41i1""ll

00.

N<rr

wnuT-lf?[

Cl?T

~
c#t

c#t ~

fl'lfll~e)

1Tm

traTfUrCfl Cfll<f. ~

1Tm

&RT ~

J1llTT4T ~

Cl?T ~

If?[ ~

Cl?T <mT ~

CfCn 31 q R q ct'i ~~ C'l

mI

it ~

c#t ~

*~ ~

fu~

c#t

it ~0f

it. ~

~.

it ~

If?[

x=rr~

f.1~ild

m1ft I

it ~/~~.

c#t ~

*m

m~ w ~

fctcrxur.

LR ~

Cf[[ ~

LR ~

cRtlffi ~

&RT ~

8'pf>

31f'ClR

Xiil1 it fcpm

16.

I <r5 3fj41O

"flWf ~

c#t CJCIT I 3Wl#r

\3~ c;ell x <r5 Xjf.1~il d CR

18.

.me ~

LR

c#t ~I

Cfl W.QlR

ET f.111'ICfflI &RT \ifffl ~-

I ~

'CPllll!>lRl. ~d'iq=4T
17.

c#t <fORT ~

31f'ClR LR ~

31Wn

-g

<tt ~

em ~

~'fC!1~~c3lJll) ?'CHlcllvj't. ~

Cl?T ~

d C'llCfl~c; I I q R,ll Cffll ~

I~

fcp

~0f

3ffi'r1

3Tnj ~:(31) 31jXfRld

I 31jxtRld\i1

\i1IRl

crif

(~) ~

'i\i11 Rl

"'(90110

"WX1'i" *

f.111liljfllx

c#t 3D<] c#t <fORT 01 ~

~0f

iil4Gu;S

~
~

>fCfllT

3D<]

ft~

2015 c#t

3D<] ~

30 ~

it ~ <tt ~
it c#t ~

*~.QlR

\ifffl ~

'CP\\1"1xi II <t> "WX1'i" &RT "fI11(:T-"fI11(:T LR

"iflA" ~

FclCflC'lill Ifcmcrr

I~

I 'CP\\1"lfJlI<i> * ~

LR 35 ~

1"[<) f.1c'hlT

l1f%c;rr3IT

C1W

m1ft1 ~

3D<] ~

tF c#t ~

m1ft I

it

:-

it ~

cgc;T

100 3tcp ~

1"[<) ~. \ill" f.1 h1 Ri Rsl d 3fj41O

~:

TI-

~"4G

25 3tcp

fctfmr~~

it ~.t/~.tcp
it ~.t./~.tcp

1. !>llfifTlCfl ~
01.

2. !>llflfTICfl ~

(~0f

~.~.~.
02.

04.

>rfu

Cl?T ~

it

(~

f.'rmmr
m

3ffi1Ii

em 5RT ~)

f.1~~ICfl *

(~)

Xiil1 it. 10 3tcp

>rfu "fI1{)C'1"

10 3tcp

~.I

!>lCflI~ld

If?[ (3iC1xl~ll

3tcp. ~

~-3

"RR-2

15 3tcp

3tcp

If?[)

!>lCfll~ It1 m

~.~.

~.

"C;f1. "C;f1.

(~/~

Xi tf Rh cil c: 1:ffi1)

;@ C'l~ c;

it ~

05 3tcp

3f~

~"RRLR~

cfrfC
05.

20 3tcp

m~LR)

~
03.

\Jf+1T CflFr c#t

"4Tff. ~
~

(~)

(~\Jnf.111Rll

I~

wmfif.1Cfl

~.~.~.

~IIFcR1Cfl

<:1"~

it traTfUrCfl I~~
fTl Cfl \3q cp ~'j I RCflT<TI it Cfll<f
iit\IFcltllC'lll

3ft tll

>ITm"4 liR I~al


~ eN ~
~

"l'l".

10 3tcp

(~)

xi 14 \i1f.1 Cfl

Cl?T 2 3tcp ~)

x=rr~

15 31q)

06.

(~)
~

..-L~

it ~

fctfm;
01.

3ffim

1. smifTl ~

~l /~.~

2. SllfifTl

~.t/~.~

(~~

"WtT ~
~

03.

cfi l:fffi,

~.~.~.
02.

25 3{q)

(~)

~
eM f.1mfur

\Jfl1T ~

~
~

20 3fcp

q?f ~

3fFclB

"WtT f.1~~I

(~

fcW:r em ~ ~)
cfi "Wi ~, 10 3fq) >lfu" ~

(~)
10 3fq)

'R)

c;rs::r ~

SII~ld

~.

"flt. "flt./

~ SII~ld

"WtT lf5f (3id'!I~<1

ffiX-3

3fq), ~

3fcp

ffiX-2

15 3fcp

"WtT lf5f)
(~ /"flt

~.~.~.

04.

cBe l:fffi) / IdlC"l~ < l'i ~

f121fq)

05 3fcp

3l~

~ffiX'R~

tfrR ~.~.~.
05.

(~ \111f.1<1Rli

3l~ dl fTl

/ f.tJfr

f114\i1f.1

l'i tr~/~

ligIFcl'aIC"l<1

/ f.1cnrm it

cBT

ffiX

qJT<i q?f 2 3fcp

10 3fcp

(~)

~)
~ <1Fcl'd X1T~

15 3{q)

06.
\1l

(~)

R:! :R;c:
fctfm;

01.

~il
~'t1'It

3ffim

~l/~.~

2. SllfifTl

l'i ~:~./~.~

cfi l:fffi,

(~)

~
cBT f.1clmr ~

\Jfl1T ~

20 3fq)

fcW:r em irtt m~)

(~)
10 3fq)

~.~.~.~
~

03.

25 3{q)

1. SlIf1fTl ~

(~~
02.

11G

c;rs::r ~

SII~ld

~.

"flt. "flt./

~ SII~ld

"WtT lf5f (3id'!I~<1

ffiX-3

3fq), ~

3fcp

ffiX-2

15 3fq)

lf5f)
~.~

(~/m

~.

..

04.

< l'i ~

{121 fq) ~ c l:fffi) / IdlC"l~

05 3fcp

3l~

~ffiX'R~
~
05.

(~\111f.1<1Rll ligIFclWC"l<1 /QIC'11eCA"ICh

=r=mr ~

/ f.tJfr

f114\i1f.1Ch

m~ ~ tr~

/~

/ f.1cnrm l'i

3l~tll fTl cb ~

eM

ffiX

q)j(f

q?f 2 3fcp

10 3fq)

(~)

~)
~ <1fcl:C1 Ch X1T~

15 3fcp

06.

(~)
,-,Cf'1II~lq'111G

(~~

cfi l:fffi,

3ffim (~

02.

(~~

cfi l:fffi,

03.

~.

"flt. "flt./

04.

05.

~.

~.

eM f.1clmr ~

fcW:r em Ml

~.

3fq) /"flt-3

/f.1GlT
-qf(an

(~-2

2 3fcp 3l~

"eCAl"

~ <1Fcl'd Ch X1T~
06.

ligl FclWC"l<1/QIC'1i
xiI4\i1f.1Ch

\Jfl1T ~

3i1Cl~<1Ch

fcW:r em ~

cBT f.1mmr ~
l'i)

\Jfl1T ~

1dl('1C~g l'i XT\Rf-

03.

50 3fcp

3ffim

fctfm; ~
01.

tq

ffiX-

cf

m~

3l~SllfT1Ch ~

~)

(~)
05 3fcp

3fq) {l21fq)~c

~)
05 3{q)

1ffil)

05 3fcp

3 3fq)

~~
-.:;

l'i tr~/~

/f.'lcm-m l'i ~

(~\J1"if.1<1Rll

LR

~
ffiX

em

cBT

05 3fq)

(~)

1 3ic:rJ ~ffrcd)
20 3fcp
10 3fq)

(~)

g f.1mfuf '"'14dli ~

~lJ~dl ~ ~

:-

(3T) ~/~(1) ~

3Th \;l1t/\;l1.-tc.n -q

if mt/m.-tc.n

t/\;l1.-tc.n ~ ~ c.nTt '4T, 3Th <:T~


(2)

cffi:c ~.-it.

~Cf)I ~I'i

"Q'Qfl1

-q ~.-it.

-it. t:9T5!T em- ~

~2lT ~.

3T~

3T~

~8l1

~81

m{/m.-tc.n 3Th \;l1.

Cli t9 .=\1 <Ol

'CflX'iT, 3~

~-

fua:rur/m/~
~

05 crf

~,

-q ~

-q

-q ~

31J11Cf CR fct-crR ~

51

cTi ~81

tt

-qfiTa:rur,(1Cf).-flc6l ~/m-LJ'?f
~

fcn ~

~2lT

t ill <rg ~~

~\ijI~f.1ll,

~Truq?f

~.

xm

irT

CBT ~

cTi ~

3lICl~<:lCf) ~

~
~
if mt/m.-tc.n 3Th \;l1{/\fT1-tc.n -q 1".lw-r 9~LJfl ,)T~
~81
\;l1. t /\;l1.-tc.n if c.nTt '4T 51, 3Th <:T~
~
-q ~.-it. 3TWlf ~811

(2)

cffi:c ~.~.

-q ~

fua:rur/~/m

t:9T5!T

em- ~

05 crf

'CflX'iT, ~
CBT~,

-q ~

51,

vn-i11

(1)

~.-it.

vfr QfilR"iQc~

Cf)14Cf)1~, Fc1~cY!~UI,ljUIClct11 ~,
0rr~

m{/m.-tc.n

02 ~

~
~
if ~{/-6ltcn
3fR \'1~/~.tcn
/~.tcn 3fR ~{/~.tcn
B it cir~ ~ I

(~) 3lffl-R:c ~-

'11c:- ~

cffi:c ~.-it.

(c;) ~

e:CM')I~lI'i

'11c:- ~

if

"Q'~

CBT 31J11Cf

3T2fCTT ~iff

4\'"1('1+1 ~

31lq~<OlCf) ~

11RICfT ~

4\'"1cF1 ~

m-2lT ~ ~\J~f.1<:jftrr

31lq~llCf)

Ch'l ~T

3ffi

Cli'(9...i>I<Olt I

~ ~.t

cTi

~,

qfilfflqc~-

~Cf)I~I'i ~2lT

/-qtcT

CBT ~ Cf)I ~I'i / ~3TR

(I")

~-

xm LR

(w ~)

VlA CR, ~fa1'TI

l'lCf)I~I'l/~3TR/~,

cTi ~

~'I~

CBT 31J11Cf

01ICl~<OlCf)~

\J1T'ffi

-m~

crf

13

~a:rfUrq) ~

cTi ~

(w ~)

CBT 01j11CT,~

3Th /<n ~

cTi ~

31J11Cf

m-r ~

CBT 31J11Cf

fua:rur 3Th /<n m

10 crf

if ~

VfR'JT :'( ~

(~l<"Jllil)

INSTITUTE OF TECHNOLOGY, I(ORBA (C.G.)


APPLICATION FORM
(Use separate from for each post)
Advertisement No.Demand Draft No

.
Amount Rs

Date:

Post applied for :

To be filled in by the office


';llioll No.
Date

I p!

.
Affix recent
self attested
colour
photograph

(1)

Name (In Block letters)

(2)

Father's Name

(3)

Mother's Name

(4)

Date of Birth (Attach Certificate)

(5)

Gender

(6)

Address for Correspondence

Phone no. with code

Female

:MaleD

Mobile

1\'0

E-mail
(7)

Category
(Tick Mark & Attach Certificate)

(8)

Education Qualification

:scD

ST

DOBCDGenD

(from high school onwards)


-,

S.No

Name of
Examination
Passed with
Branch (if
applicable)

Board/University

Year

Max/Obtained
Marks

Roll No.

I
I

Percentage
/Division

(9)

Experience Details (Attached documents/certificate)


Name of
Organization/Institute

S.No.

Total Experience years

Months

DII

Post

ration/period
From
4

(10)

Other extra curricular activities /papcr published:

(11)

List / No. of enclosures

To

Remarks

Day

.
:

') <,CLARATTON
I hereby solemnly declare that all the above

furnished

informationts:

the best of my knowledge and belief. I am also fully understand

awar

by me are true and correct to

that ifat any stage, it is found that

any attempt has been made by me to willfully conceal or misrepresent the facts, my candidature may be
rejected and my employment may be terrnin: .. I.
Place:

Date:

Signature of Candidate
Name:
I

ddrcss

Contact

No

You might also like