NATIONAL INSTITUTE OF TECHNOLOGY,

DURGAPUR
MAHATMA GANDHI AVENUE, DURGAPUR-713209, WEST BENGAL, INDIA

Please affix
recent passport
size photograph

Advertisement No. & Date:

Post Applied for
Department
Specialization

:
:
:

1. (i) Full Name(in block letters)

..

:......

(ii) Fathers/Husbands Name

...

:....

2. Date of Birth:.. Age (as on date) :..(attach

photocopy of the certificate)
3. (a) Nationality : (b) Gender:
Male/Female..
(c) Category: (OP/SC/ ST/ OBC/ OBM/ PWD): .(attach
photocopy of the certificate)
(d)Marital Status: Married/Unmarried/Divorced
(e) Native Place :
.........................................
......
(Town, Village, District & State)
..............................................................
.....
...
4. Postal Address for correspondence:
...............................................

Page 1 of 8

....
..
.
.....
..Pin Code: .
...
Phone No.: Office:... Res.:....Mob. No.:
............
(with STD Code)
e-mail ID: (i)... (ii)
........
5. Permanent Address:
....
...
(Mention Tehsil, District and
State you belong to)
....................................
.
....
..Pin Code
.....................
6. Enclosed Bank Draft of Rs. (Rupees in
words), Bank Draft no.. dated...of(Bank) to
NIT Durgapur payable at SBI, R.E. College Branch (Code -2108), Durgapur713
209.
7. Educational Qualifications (from matriculation onwards); attach photocopy of the
certificate and grade cards:
Sl.
No
.

Examination
Passed

Name of the
University/
Board

Year
Subject/
of
Specialization
Passin
g

% of Marks/
Grade
(CGPA)

Divisio
n/
Class

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8. Prizes, Awards, Distinction received etc. (if any), attach photocopy of the certificate:
....

.
......

..
9. (a) Post held at present (if any), attach copy of appointment letter, joining office order,
etc.:
Post held at present

Date of
Appointment

Nature of the Post

(Temporary/Probatio
n/
Permanent)

(b) Present Pay Scale:

.
Basic Pay:.

Name & Address of

Employer

AGP/ Any other Pay:..

Dearness Allowance: Gross Emolument:..

(c) Type of organization (Government/Semi Government/Govt. Sponsored/Autonomous

Body/ Private etc.)
....
....
10. (a) Research Activities (attach photocopy of the sanction letter):
Sl.
No
.

Sponsored/
Consultancy
Projects

Duration
(date)
From
To

Sponsori
ng
Authorit
y

Funds
sanctioned

Present Status
(Completed/
In progress/
Proposals under
review)

(b) Thesis supervised: Ph. D. / PG/ UG Programme:

Page 3 of 8

Sl.No.

Degree
(Ph.D./ PG/
UG Degree)

Status
(Degree
Awarded)/
In progress

Brief Title of Thesis

Sole /
Principal or
CoSupervisor

(c) List of Publications (National and International Journals), attach photocopy of the first
page:
Sl.
No.

Name of
Journal

Volu
me
No.

Month/
Year/Page
Nos.

Authors

Title of the paper

SCI
/SSCI/
AHCI
journ
al

(d) Conference/Seminar (National and International level) participated (Applicable if full text
of paper is published), attach photocopy of the first page:
Sl.
No.

Name of the National or

International Conference/Seminar

Month/
Year

Venue

Title of the paper

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(e) Summer / Winter Schools/ Training Programmes attended, attach photocopy of the
certificate:
Sl.
No
.

Title

Venue

Duration

Sponsoring
Authority

11. Patent (filed/awarded), title, number; attach photocopy of the application first page/
certificate:

12. New projects introduced in the laboratories:

13. Any other achievements:

14. Membership of Professional Bodies:....
(Including Membership no.)
.
.
15. Extra Curricular Activities/Hobbies:.

16. Please give details of two referees:

(i) Name:
..

(ii) Name:

Designation:..

Designation:

Full Address:.
...

Full Address:

..
...

Page 5 of 8

Contact No. ..
.

Contact No.....

E-mail:...
.

E-mail:

17. Any other relevant information

DECLARATION
I declare that the statements made in this application are true to the best of my knowledge
and belief. I understand that misleading or wrong information supplied may lead to
summary rejection of application /appointment (if found subsequently).

Date:
-----------------------------------Place:
Signature of Applicant)

(Full

Page 6 of 8

Information Summary Sheet

Sl. No.:

Advertisement No. & Date:

Name:

Educational Qualifications
Examination
passed [Secondary/
H.S.(+2.)/UG/ PG /
Ph.D], discipline
& University

PassingYear of

Details of the
Candidate

Post applied for (with AGP):

% of
Marks/
Grade
& class

Subject/ Specialization Experience (if any)

(Particularly in PG and in Teaching /
PhD levels)
Research
Organization/
Industry/

(i)

Date of Birth:

Other
research
activities

Name of the
Organization

National
journal No. of Thesis
(SCI/SSCI/AHCI) - Supervised:

Govt. / SemiGovt./ Pvt.

PhDNational
journal
(non-SCI/SSCI/
PGAHCI) UG-

Address:
(ii)

No. of Research
Publication in
Journals/
Conference
proceedings

(iii) Contractual /
Regular
Service with
Pay scale

Age as on date
(iv) Years of
Service (with
date of joining)

Any
other
informati
on

Remarks

Name of Department:

International
No. of
journal
sponsored
(SCI/SSCI/AHCI) - projects:
No.AmountInternational
journal (non-SCI/ StatusSSCI/AHCI)Patent:
No.
Conference
proceedingsStatus-

Category
OP/ SC/ST/OBC/OBM/
PWD:

N.B.: Summary Sheet to be filled by the candidate. Remarks column and Sl. No. are to be filled by NITD Office only.

Page 7 of 8

Signature of the Candidate with date

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