THE GANDHIGRAM RURAL INSTITUTE DEEMED UNIVERSITY

Under sec.3 of UGC Act 1956 vide Notification No.F.9-1/76-U.3 dated 03.08.76

GANDHIGRAM -624 302, DINDIGUL DISTRICT, TAMILNADU

Advertisement No.1/Estt.2/2011-12 Advt. Date:10.11.2011 (www.ruraluniv.ac.in)

Affix a passport size photograph here duly signed by you

Separate Application form should be used for each post. Please see the general instructions before filling up the Application Form

APPLICATION FOR THE POST OF ___________________________________ _________________________________________________________________ 1. Name in full (Block Letters) : ___________________________________________

2. Name and address of Father/Mother/ :____________________________________________ Husband (in case of married woman) ____________________________________________ ____________________________________________ PIN:____________________ 3. (a) Address to which communications : ____________________________________________ are to be sent ____________________________________________ ____________________________________________ PIN: _____________________ (b) Permanent address : ____________________________________________ ____________________________________________ ____________________________________________ PIN: _____________________ e-mail id:_____________________________________ (c ) Contact Phone No:_____________________Mobile No:__________________________ 4. Gender 5. Nationality and Religion 6. Date of birth and age (a) Place of birth
(a copy of proof should be attached)

: Male/ Female : ____________________________________________ : _______________________________________years : ____________________________________________ : ____________________________________________

(b) District and State

7. (a) Community

: ____________________________________________ Yes/No

(b) Whether the applicant belongs to SC/ST/OBC : SC/ST/OBC

(b) Whether the applicant belongs to Physically Handicapped category : Yes/No

If Yes OH / VH Disability(%) __________

8. Educational qualifications : th (a) 10 Std onwards Examination Board SSLC/Matric or equivalent PUC/+2 (HSc) or equivalent Diploma (b) UG Degree onwards Sl. Degree Subject/ Specialization No.

Month & year of passing

Marks obtained

Overall percentage

Class /Division

University/ Institute

Percentage/ Class/Grade

Year of Passing

(Enclose attested copies: Start from the most recent degree and list upto Matriculation or SSLC)

9. Whether qualified NET/SLET/SET : Yes/No/Exempted If Yes, give details (a copy of proof should be attached) (a) Subject : ____________________________________________ (b) Regn. No. and Year of passing : ____________________________________________ (c) Academic Distinction, if any : ____________________________________________ (eg., any prize, medal, certificate of merit with area of specialization)

Signature of the Candidate

10.(a) * Teaching experience: (starting with the most recent) No. Institute/ Designation Duration Length of University service in From To years 1. 2. 3. 4. 5. 6. * Experience as Guest Faculty is not to be included (b) Administrative/Research experience: Post held with scale of pay Period From To Name of Institution

Whether UG/PG

Permanent/ Temporary/ consolidated

Nature of Duties

11. Present employment (a) Name of the Organization (b) Post held (c) Grade (d) Pay Band (e) Date of Appointment

:____________________________________________ : ___________________________________________ : ___________________________________________ : ___________________________________________ :___________________________________________

(f) Whether Permanent/Temporary/ or on Probation : ___________________________________________ (g) Whether State/Central Govt./ PSU/Private : ___________________________________________ 12. Membership in Professional Societies : _____________________________________

(Name of the Society and Country of incorporation)

13. Post Doctoral Fellowship, if any (National/International): No. Name of Award/ Fellowship Name of Institute/ University

Duration of the program

Special Distinction If any

Signature of the Candidate

14. Research Project undertaken: Sl. Sponsors name Project title No. 1. 2. 3. 4. 15. Thesis Supervision/Guided: No. Experience in guiding Awarded research (in figures) 1. 2. 3. Ph.D. M.Phil. PG/ PG Diploma

Amount Sanctioned Rs.

Period of Project

Year of Completion

Under submission (in figures)

In progress

Remarks

16. National/International Symposium/Workshops/Winter/Summer Schools organized by the applicant: Sl. Title Sponsors Duration Co-convener No. 1. 2. 3. 4. 17. Research publications (in ISBN/ISSN numbered Journals and Books) Sl. Publications No. 1. Books (as the only author) 2. Books (Coauthored with others) 3. Edited books (as the only editor) 4. Books edited with others 5. Refereed International Journals 6. Refereed National Journals 7. Publications in refereed conference proceedings 8. Publications in non-refereed conference proceedings 9. Other publications

Published (in Nos.)

Signature

of

the

Candidate

18. Conference presentations/attendance (Details to be attached separately) Sl. Details National No. (in Nos.) 1. Plenary Lectures 2. 3. 4. 5. Invited talks Contributed oral presentations Poster presentations Only attendance

International (in Nos.)

19. UGC Refresher Courses/Orientation Courses attended: 1. No. of Refresher courses attended 2. No. of Orientation courses attended

20. Experience in Extension Work : (Use separate sheets, if necessary)

21. Travel or study abroad Country visited From

Period

To

Purpose of visit

22. Knowledge of languages Languages Ability to speak

Read and Write

Speak, read and write

23. Any other fact(s) you would like to present for consideration in support of your candidature ;
(information regarding the qualifications, experience etc. desirable for the post prescribed may be indicated here). Use separate sheets, if necessary

Signature of the Candidate

24. Registration Fee Details (a) Amount of Demand Draft DD Number & Date (b) Drawn on (Drawers bank) with Code No.

: Rs. _______________________________________ : __________________________________________

(c) If remitted in account No.10000 at Canara Bank, GRI campus) Amount and Date of remittance : Rs._______________Date:___________________ (counterfoil should be attached) 25. Name and address of not less than two persons (not related by blood or marriage) to whom confidential reference could be made. They should be in a position to evaluate you for the suitability of the position you are seeking now. ( All of them should be familiar with your Academic /Professional work) 1 2 3

Phone: Email:

Phone: Email:

Phone: Email:

26. Character & Antecedents Report

: Remarks

Subject Have you ever been subject to any disciplinary action, as a student and/or as an employee. If so give full details Have you ever been dismissed/suspended from service/employment, if so please give full details Were you involved in any criminal case? If yes, give full details Is any criminal case pending against you in the court? If yes, give full details

Signature of the Candidate

27. List of enclosures 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

I hereby declare that the statements made above and information given in the application are true to the best of my knowledge and belief. At any stage if any of the above information furnished by me is found to be false or incorrect, suitable action may be taken against me. If selected, I promise to abide by the rules and regulations of the Gandhigram Rural InstituteDeemed University. Place: Date: Signature of the candidate

Endorsement of the present employer (if already employed)

Signature of the Employer

Office seal with date:

Name: Designation: