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Place of Interview: _________________ Date: _________

PLACEWELL HRD CONSULTANTS


(Licence no. B-0148/AP/PER/1000 Plus/5/7143/2005)
7-1-58/104/1/A| Surekha Chambers | Opp: VIP Showroom Near
PHOTOGRAPH
Lalbanglow | Ameerpet | Hyderabad - 500 016
Ph: 040-44360977/976 | Email ID :- ethiopia@placewell.in
(www.placewell.in)

APPLICATION FORM

APPLIED FOR DEPARTMENT __________________________ SPECIALIZATION_________________________________________ DESIGNATION________________________________

I) PERSONAL INFORMATION :( In block Letters Only)

Full Name _____________________________________________DOB (DD/MM/YYYY): ___________________________Age:_________Gender:______________

Marital Status: No. of Children: __________Mobile No: _________________________________ E Mail: ___________________

Address: ___

Pass Port No: __________________________ Validity Date: ___________________________________ Skype Id:_________________________________________________________________

Earlier years of experience in Ethiopia Universities (Including with University Names) ______________________________________________________________________

_______________________________________________________________________________________________________________________________NOC taken (Yes / No)__________________

II) EDUCATIONAL INFORMATION:

QUALIFICATI FIELD OF UNIVERSITY / TYPE OF UNI ADMISSION THROUGH ADMISSIO MODE OF


ON SPECIALIZA INSTITUTION VERSITY/ N AND EDUCATION
TION INSTITUTE
ATTENDED GRADUAT
(CA MPUS ION
WHERE YEARS.
STUDIED) TOTAL
DURATIO
□ IIT/IISc □ National Level Entrance Admission: □ Regular
□ NIT/REC □ State Level Entrance _______________ □Part time
PhD □ Government □ Institute level entrance □ Distance
□ Deemed □ Sponsorship Graduation: □ Other
□ Affiliated □ Management quota If any other ______________ (Specify)
□ Private quota used give type of Duration:
□ Others quota : _______ ______________

□M.Tech □ IIT/IISc □ National Level Entrance Admission: □ Regular


□ME □ NIT/REC □ State Level Entrance _______________ □Part time
□M.Arc □ Government □ Institute level entrance □ Distance
□M.Sc □ Deemed □ Sponsorship Graduation: □ Other
□MCA □ Affiliated □ Management quota If any other ______________ (Specify)
□ Private quota used give type of
□MBA Duration:
□ Others quota : _____________________
□M.Phil ______________
□MS/MD
□M.Pharmacy
□Others
□B.Tech □ IIT/IISc □ National Level Entrance Admission: □ Regular
□BE □ NIT/REC □ State Level Entrance _______________ □Part time
□B.Arc □ Government □ Institute level entrance □ Distance
□B.Sc □ Deemed □ Sponsorship Graduation: □ Other
□ Affiliated □ Management quota If any other ______________ (Specify)
□MBBS
□ Private quota used give type of
□B.Pharmacy Duration:
□ Others quota : _______
□Others ______________
III) EXPERIENCE:-

TEACHING EXPERIENCE
INDUSTRIAL TOTAL
QUALIFICATION TOTAL YEARS OF EXP. EXP
RANK DURATION UNIVERSITY / INSTITUTION
TEACHING EXP
Professor
Assoc. Professor
After PhD
Asst. Professor
Lecturer
Professor

After 2 nd Assoc. Professor


Degree and Asst. Professor
before PhD
Lecturer
After first Lecturer
Degree before
2 nd degree Teaching Assistant

TOTAL
IV) List of subject (courses) you thought (Prioritize according to your preference):

________________________________________ ________________________________________ ______________________________

________________________________________ _________________________________________ ______________________________

________________________________________ _________________________________________ ______________________________

v) Number of Publications: International Level ___________ National Level _________ Conference_________

VI) No.of Ph.D Students Guided_______________ VII) Minimum time to required to join _____________________________________

I, the under signed, have completed the above information in good faith and is true to the best of my knowledge and I can provide
authenticated document on request.

NAME ___________________________________ SIGNATURE _________________________________________ DATE ________________________

FOR EMPLOYER USE


LANGUAGE / COMMUNICATION SKILLS □ Excellent □ Very Good □ Good □ Poor
KNOWLEDGE ON SUBJECT MATTER □ Excellent □ Very Good □ Good □ Poor
FINAL RECOMMENDATION □ Strongly □ Recommended □ Not Yet Decided □ Rejected
Recommended
CANDIDATE NOTICE PERIOD ___________ (Months)
SALARY OFFERED (USD) Candidate Status
___________ $
□ Accepted □ Not Accepted
ADDITIONAL COMMENTS

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