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Application No.

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(To be entered by SAMEER)

Society for Applied Microwave Electronics Engineering & Research

Dept. of Information Technology Ministry of Communications & Information Technology, Govt. of India IIT Campus, Powai, Mumbai 400076 Website : www.sameer.gov.in

(TO BE FILLED IN BY THE APPLICANT IN BLOCK LETTERS ONLY) ADVT. NO. & DATE POST APPLIED FOR CODE

APPLICATION FORM

Important: Use only A4 size paper for application and other testimonials
1 2 3 Name in full (Shri. /Smt. /Ku.) a) Father s name b) Mother s name a)Date of Birth (in Christian era in figures) b) Age as on closing date mentioned in Advt. 4 5 6 a) Sex b) Marital Status Nationality a) State Category (General/SC/ ST/OBC) (attach certificates if applicable) b) Religion Type of Present Employment, if employed (Central / State Govt. / PSU/Others) Permanent Address GEN SC ST Date Years Male Month Months Year Days
Female

Affix recent passport size photograph here

Please Tick

OBC

Please Tick

7 8

Address for correspondence

City: Pin Code: Tel. No. with STD Code Mob. No. Fax No. e mail: 10 Nearest Railway Station

City: Pin Code:

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Educational Qualifications # *Exam passed Year of passing University Institution Board Subject in which degree is awarded Specialisation as reqd. in advt. (if any) **% of Marks

* In chronological order from X Standard (SSLC/HS/HSC) onwards, ** In case of CGPA/CPI, please give marks in percentage also along with the conversion formula, # Specify the gap with reasons in Education career, if any. (Use extra page if necessary) 12 Whether receiving any Scholarship / Fellowship from any Agency If yes, indicate: i) Name of Agency ii) 13 Amount of Fellowship/ Scholarship YES / NO /N.A. iii) Duration (since when) a) Have you qualified GATE/NET(JRF)/NET If yes, give i) Name of the Test ii) Year of Passing YES / NO iii) Score b) Have you registered for a higher degree if yes please indicate i) Title of Degree ii) University / Institute iii) Date of registration iv) Likely date of completion 14 Professional Training Organisation From To Details of Training YES / NO

15

Research / Project work Title of Project / Dissertation / Thesis No. of Papers Published (Separate sheet may be used)

16 17

Areas of Specialisation/ Research Employment Record*

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(Attach separate sheet in following format, if necessary) Name & address of employer/ Organisation /Institution Period of service Designation of the post held To Scale of Pay of in each post Detailed description of work

Reason for leaving

From

* Specify the gap, if any 18 Present Basic pay in Rs. Total Emoluments in Rs. 19 Are you under any contractual obligations to serve Central YES / NO /State Govt./Any other Public Sector Undertaking or Autonomous body and if so, give details (Attach NOC if applicable) YES / NO Have you been interviewed for any recruitment / selection by SAMEER during the past one year? If yes, give particulars Sr. Particulars Name of Posts & Discipline No. Date of Advt., Advt. No.

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Date of Interview

Result

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Details of relatives already employed in SAMEER Sr. No. Name of the Relative Relationship Division in which employed Post Held

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Give Name & address of two referees (Gazetted Officers/Professors of reputed academic Institutions/Public Sector Executives etc Not related to the candidate) and attach certificate from them

1.

Name:

Address :

2. Address:

Name:

23

Any other information you may wish to add, including extracurricular activities (Use separate sheet if necessary).

24

Declaration I declare that the above information is correct and complete to the best of my knowledge and belief. If at any time it is found that I have concealed/distorted any information my appointment is liable to be terminated. Place: Date: Signature of the Candidate