NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA SURATHKAL MANGALURU - 575025, KARNATAKA, INDIA. SPECIAL RECRUITMENT DRIVE FOR FILLING UP SC/ST/OBC BACKLOG VACANCIES FOR ASSISTANT PROFESSOR POSITIONS II ROUND (Please type or write using BLOCK LETTERS) Advertisement No. Post Applied Name of the Post: AGP: Recent Passport size photo Department 1. Name in Full a) Father Name Spouse Name b) Gender Male Female Trans gender c) Marital Status Married Single d) Category SC ST OBC Percentage of Disability for PWD Candidate VH OH HH 2. Address: (a) Permanent: Address Line 1 Address Line 2 Address Line 3 City Pin Code State (b) Address for Correspondence Address Line 1 Address Line 2 Address Line 3 City Pin Code State
Mobile Telephone (with STD Code) Email Office Res. No. 3. Date of Birth: 4. Nationality Day Month Year 4. Present Employment: Designation Organization Date of Joining to the present post Scale of Pay Rs. Current Basic Pay Rs. Total Emoluments (per month) Rs. AGP / GP: (if applicable) 5. Areas of specialization: 6. Academic Career Record starting with SSLC: (Attach photocopies) Certificate/ Degree [UG & PG] Year School/ College Board/ University Class/ Division Percentage/ CGPA Remarks/ Status 10 th Level 10+2 Level 7. Academic - Doctoral Degree [Ph.D.] Details: (Attach photocopies) Thesis Title From Date To Date Institute / University Guide / Mentor Mode ( Full/ Part Time) Final Viva Voce Date Award Date Page 2 of 6
8. Post Doctoral Work: (Attach photocopies) Career From Date To Date Institute / Organization Guide / Mentor Field of Research Work 9. National/State/Others -Test Scores/ Ranks (Attach photocopies) Examination Year Branch / Area of Specialization Score Rank Percentile 10. Employment Details (Particulars of your past employment in Chronological order starting with current employment -Attach photocopies) Employer Position Held Date of Joining Date of Leaving No. of Months/ Years Scale of Pay & GP/AGP (If Applicable) Gross Pay 11. Total Experience (Number of Years and/or months) Teaching Experience Research Experience (Post-Ph.D.) Industrial Experience 12. Teaching Experience (Number of Years and/or months) Academic experience as applicable (month / year) in the posts indicated or equivalent Assistant Professor or equivalent Associate Professor or equivalent Professor 13. Subjects Taught (Last 4 years) Title of the Course taught Year U.G. / P.G. Approximate No. of students Institution/University Page 3 of 6
14. Research guidance Completed Ongoing Ph.D. P.G. Ph.D. P.G. 15. a. Publication details - No. of Papers: Journal Papers Conference Publications International National b. Provide best papers details (maximum 3) Author Title Journal Volume Pages Year 16. Books / Chapters Published & E-learning materials Developed (last 4 years) 17. Patents 18. Sponsored Projects (Project handled as Principal Investigator in last 4 Years) Funding Agency Title of the Project Project Cost Duration Current Status Remarks 19. Consultancy Project (in last 4 Years) Funding Agency Title of the Consultancy Work Project Duration Project Cost 20. Professional Training Received / Summer / Winter Schools attended (Last 4 years - Attach photocopies) Year Nature of Training Duration Organization where training was provided Page 4 of 6
21. Conferences / Seminars / Workshops attended (Last 4 years - Attach photocopies of the certificates) Year Conferences / Seminars /Workshops attended Title of paper presented 22. Industrial Experience / Interaction (Attach photocopies): Organization Nature of work Period 23. Continuing Education Programmes /Short Term Courses/Workshops/Seminars etc. organized (Last 4 years): Title of Programme Period Funding Agency 24. Experience in Administrative Positions, Curriculum and Lab Development, Student Welfare, Professional and Outreach Activities: 25. Awards and Recognitions (Attach photocopies): 26. Any other relevant information you may like to furnish: Page 5 of 6
27. Names and addresses of two Professional References: (Attach Testimonials of Them) Name 1. 2. Position/ Designation Address Phone & Fax Mobile E-mail 28. Please indicate how in your opinion you can contribute to NITK s growth. (Use a separate sheet, if required) (Limited to 250 words) 29. I hereby declare that the entries in this form are true to the best of my knowledge and belief. I understand that my Candidature will be cancelled if any of the information is found to be false or incorrect. Further, if selected, I will abide by the rules and regulations of the Institute and also the directions given to me from time to time. Date : Place : Signature of Applicant List of Self Attested enclosures / certificates / testimonials (tick the appropriate ones) 1. Proof of Date of Birth 7. Conferences/Workshops attended and presented 2. Category certificate (SC/ST/OBC/PWD) papers 3. Salary certificate / pay slip 8. Sponsored and consultancy projects 4. Academic records (SSLC marks card onwards up to Ph.D.) 9. Workshops / Conferences / Short Term Courses organized 5. Experience certificates 10. Publication and Patents details (list and reprints) 6. Training / Summer / Winter Schools attended 11. Awards and recognitions 12. Testimonial To be filled in by the forwarding authority (For Employed Persons only): Date: Forwarded to the DIRECTOR, NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA, SURATHKAL. The applicant has been working in this Institute / organization as. since. and is still in service. We have no objection to his/her candidature being considered for the post he/she is applying. Place :.. Seal Signature Designation : Page 6 of 6