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    FILLED FORM

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    of 2

    NISER

    NATIONAL INSTITUTE OF SCIENCE EDUCATION AND RESEARCH BHUBANESWAR


    (An autonomous research institution under Department of Atomic Energy, Govt. of India)
    Jatni, Khurda, Odisha - 752050
    Research & Development Section

    faT9THeT: NISER-IOP /Vigyan-Pratibha /R&D /02 / 2024-25

    Application for recruitment to the post of Project Clerk

    1. T TH (EY2 ATÌ ) | Full Name (In Block Letters):


    SAMEEB KUMAR DAS
    2. fraT /ft 1 TH | Father's / Husband's Name:DINABANDHU DA
    3. -fafr | Date of Birth 22l0 1g99
    4. 3HAge as on (eais 05.05.2024)
    AT AERGABH PD ACRGARH
    Postal Address for Correspondence pSKHANTAPADA DIST ALA0BE
    PNIChotD 4TATG 0NHA

    6. TE YT | Permanent Address :AT MAGONIAPADA PD: MALIPAL


    PA RAIDAIA DIST BALAS

    7. (a) i R0|Contact No. :te942L9292/ss9803DA8O


    (b) IE-mail
    8. T A,TT/ A.A.TT./.NA T.fa. 3A?
    Whether belongs to SC/ST/OBCPWD
    (TIA T4T-97 7 7T HY 4T AI|Copy of Caste Certificate to be enclosed)
    09. 'afur T4aT (aTE
    )|Educational Qualifications (Starting from Graduation):
    Name of the at |Year of fayt Subjects
    Board/ Univ/ Institute Percentage of
    Examination Passing Marks

    BSE,DISttA PLO, CLe, TLS,


    2019

    tD42 (9C) CHSE, DDISHA |PCe


    G+RADUATI6NFMU, BALASORE O20 MEA SE,

    10. 4T4q, Tf TE T| Experience, if any:

    Name of Period of Scale of Pay &


    Organisation/ Service in Year Designation Basic/ Gross
    Nature of duties

    Empleyer & Months Emoluments


    Dreeyta
    beuity Preratoe Erenerdagmwr
    maa tehvng.

    bdlg.

    Ido solemnly affirm that the above information given by me is true to the best of my knowledge
    and belief. If any information given by me is found to be incorrect at any stage, my candidature
    may be cancelled.

    fiE Date : os|es2034 bamee Ktena Das


    T|Place : P4LASORC TATE AT ZHdTTHT | Signature of Applicant

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