GHANI

KHAN CHOUDHURY INSTITUTE OF ENIGINEERING AND TECHNOLOGY

(A Centrally Funded Technical Institute under MHRD, Government of India)
NARAYANPUR, MALDA – 732 141, WEST BENGAL

ADVERTISEMENT NO.: 01/2019

(i)Application for the Post of___________________
Photo
(ii)Department of ___________________________

(iii)Details of Application Fee Paid:

Demand draft no: Date: Amount:

1. General Information of Applicant

Name (in capital letters)
Father’s Name
Date of Birth Male/Female
Correspondence Address
Category
(General/SC/ST/OBC/PWD)
Email/Phone no.

2. Present Position
a. Designation
b. Organization
c. Pay Scale
d. Date of Appointment to the present post

E Total Experience (in years & months)

3. Educational Qualifications (In chronological order from latest to Class X level)

S. No. Qualification University Year Subject(s)/ Topic (s) % Achieved Distinction etc.
4. Does the award of Ph. D degree fulfil UGC norms of 2009 (Yes/No):

5. (a) Academic/Teaching Experience (In chronological order from latest to oldest)
S. No. Post Organization Duration Experience
From To (Yrs & M)
(b) Participation and contribution in relevant areas in higher education

Activity Organization Area of Specialization

6. Administrative experience & field out reach activities
7. International Academic Exposure, if any
S. No. Post/Assignment Organization/Institute Area of Duration
Assignment From To Yr & m

 8. Research/Scholarly Achievements
A. Contribution to Journals and Books
Activity (Editor, reviewer etc.) Details
B. Research Guidance
C. Publications
D. Participation and scholarly presentations in conferences

D.I National

S. No Date (s) Title of Conference or Institution Title/Subject of

presentation
D.II International

S. No Date (s) Title of Conference or Institution Title/Subject of

presentation
D.III Conferences/programs Organized

S. No. Date (s) Conference/Program Organized & Role Organization/Venue

D.IV Research Projects

S. No. Client/Organization Nature of Project Duration of Amount of

Name Project Grant (Rs.)

9. Consultation Experience

10. Honours/Awards & Fellowships for Outstanding Work

11. Have you ever been charge sheeted, arrested or convicted etc., (Yes/No):
(If yes, please furnish the details)

12. Details of Referees (03)

S. No Name & Address of the Referee E-mail Mobile
13. Any other information, not covered above:

14. Declaration:

I hereby declare that all the statements/particulars in this application are true, complete and correct
to the best of my knowledge and belief. I also declare and fully understand that in the event of any
information furnished being found false or incorrect at any stage, my application/candidature is liable
to be summarily rejected at any stage and if I am already appointed, my services are liable to be
terminated without any notice as per applicable rules.

Place :
Date : (Signature of the Applicant)