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NATIONAL INSTITUTE OF TECHNOLOGY PATNA

PATNA-800 005 (BIHAR)

(Application Form for Faculty Position belonging to PwD)

Advertisee!t N"# NITP$0%$%0&5

To  The Director 

  National Institute of Technology Patna

  Ashok Rapath

  Patna! "## ##$ (%ihar)

&elf atteste'

 photograph

Post Applie' for DD Number

Department Amount Date

&pecialiation Name of issuing bank  

 Name in full (in capital letters)

%# Father*s + ,usban'*s Name

'# -other*s Name

# Date of birth(please attach true copy of certificate )

  Day -onth .ear 

Age on /01//12#/$   .ear -onth Day

5# a) -arital &tatus 3 -arrie'+4nmarrie'

 b) 5en'er 3 -ale + Female

# a) Permanent a''ress b) 6orrespon'ence A''ress

Phone (with&TDco'e)+ -obile No1

7!mail ID

*#  Nationality

Religion

8# 6ategory 8%6 (9,)+57N (,,)+57N(8,)

Percentage of 'isability(please attach true copy of certificate )

+# :ere you at any time 'eclare'me'ically unfit; aske' to submit your 

resignation; 'ischarge' or 'ismisse'

from 5o

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&0# ,eti.s "/ Ed1ti"!. 2.i/i1ti"! (&econ'ary onwar's)3

7?am1 Passe' &pecialiation %oar'+4ni

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(ii) In'ustry

&1No1 Name an'a''ress of

employer 

Designation Pay!scale

From To Durationin

yy+mm+''

Reasonsfor

lea

if any

 Name of the

ournal

9ol1

.ear 

Pages

(b) Paper publications in National ournals

&1No1 Title of paper 6o!author(s)>

if any

 Name of the

ournal

9ol1

.ear 

Pages

(c ) Papers publication in International 6onferences

&1No1 Title of paper 6o!author(s)>

if any

 Name of the 6onference Date

year 

(') Papers publication in National 6onference

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&1No1 Title of paper 6o!author(s)> if

any

 Name of the 6onference Date

year 

(e) Number of 45 an' P5 stu'ents gui'e' + 8ngoing

45 P5

5ui'e' 8ngoing 5ui'e' 8ngoing

(f) Details of Ph D &tu'ents gui'e' + 8ngoing

&1No  Name of &tu'ent

.ear 

of awar'

of 

Ph1D

Title of the Dissertation&tatus

(6omplete'+

ongoing)

6o!super if  

any

&*# Sei!rs$S3"rt Ter C"rses$Ser S13"".s$

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course

&+# S4"!s"red Pr"=e1ts !derte!

&ponsoringAgency

Title of the Proect Perio' Amount 6omplete'+ongoing

Accomplishment

%0# 9e>ers3i4 "/ Pr"/essi"!. B"dies

&1No1 Name of Professional

%o'ies

5ra'e of

membership

-embership no1 with

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%'# Ne !d ddress "/ t;" Re/ere!1es3

/st Reference 2n' Reference

 Name Name

Position Position

A''ress A''ress

Phone No1 Phone No1

7!-ail ID 7!-ail ID

%1 ,id 6" 4revi"s.6 44.6 /"r !6 4"st i! t3is I!stitte@ I/ 6es? :ive 4rti1.rs 3

CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC1

APPLICANTS ,ECLARATION

I hereby 'eclare that I fulfill the eligibility con'itions to the post an' that the statementsma'e by me in form are true> complete an' correct to best of my knowle'ge an' belief1G

Place3CCCC1 &ignature of Applicant

DateCCCC11

 

 NameCCCCCCCC

 N8 8%76TI8N 67RTIFI6AT7 T8 %7 F4RNI&,7D %. T,7 6ANDIDAT7 :,8 I&AHR7AD. IN 7-PH8.-7NT> R754HAR+T7-P8RAR. %A&I&1

6ertifie' that -r+-s1!!!!!!!!!!!!!!!!!!!!!!!!!!&on+Daughter of &hri!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!is a permanent +temporary +a'hoc employee of the 'epartment+ institution+

organisation since!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1 The Department+Institution+organisation hasno obection if he+she is appointe' in National Institute of Technology Patna against the

 posts a'