Kerala State Council for Science, Technology &

Environment
Sasthra Bhavan, Pattom P.O, Thiruvananthapuram – 695 004

Application Form
Paste a recent
Colour Passport
size Photograph
1 Name of the Post

2 Name

3 Father’s Name

4 Nationality

5 Date of Birth

6 Age as on 01.01.2019

7 Address for Communication

8 Permanent Address

9 Tel No., Mob No. & E-mail Id

10 Educational Qualification ( Attach self attested copy)

Examination/ Board/University Subject Year of Class/Div %

Degree Passing Marks
11 Additional Qualifications ( if any) (Attach self attested copy)

12 Certification Course in IPR (if any) (Attach self attested copy)

13 Details of Work Experience (Attach self attested copies)

Period Name & Address of Designation Nature of Duties

the Organization
From To
(DD/MM/YY) (DD/MM/YY)

14 Name, Address & Contact Details of 2 Referees:

15 List of Enclosures :

DECLARATION:

I understand that the appointment is contractual and I hereby declare that the
information given above is correct, true to facts and nothing has been concealed /
distorted. I am aware that, if at any time I am found to have concealed/distorted
any material information, my candidature/engagement is liable to be summarily
terminated without notice.

Date:

Place: (Signature of the Candidate)