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CONFIDENTIAL

P&A Ref no:

FLUID CONTROL RESEARCH INSTITUTE

(An Autonomous R&D Institute under Ministry of Industry)

Dept. of Heavy Industry, Government of India)

Kanjikode West, Palakkad -678 623, Kerala, India.

Phone No: 0491-2566206, 2566120, 2566119; Fax: 0491-2566326

(A Premier Institute in South East Asia for R & D on flow products, Testing and

Calibration of valves, flowmeters and other measuring instruments as per ISO

requirements, Software for Design & Selection of Flowmeters / Valves and Specialised

Training Programs)

Advertisement No. :

Postal Order No. :

(Date & amount)

Post applied for :

Name in (BLOCK CAPITAL) full

Fathers name & Occupation

Present Address

Permanent Address

Telephone nos.

Date of Birth & Age

Marital Status

Nationality

State of domicile & mother tongue

Religion /Caste

Do you belong to /Scheduled Caste /

Scheduled Tribe

Languages known

Indicate specific reasons for leavingyour previous employer:

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PHOTO

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ACADEMIC RECORDS

YearCourse & Specialisation

School / College /

University & Institute

Class &

%age of marksFrom To

SHORT TERM COURSE/PROFESIONAL TRAINING PROGRAMMES:

DETAILS OF EXPERIENCE (Including present Appointment)

Year &month Employers Name &

Nature of Business

Designation Gross Monthly Salary

From To Starting Leaving/ present

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Indicate specific reasons for leaving your previous employer:

Name & address of previous employer Specific reasons for leaving

Why do you want to leave your present

employer?

Your achievements like outstanding contributions in your previous employment, sports, cultural,

literature, associations etc.

Have you ever been discharged/dismissed / terminated / or any type of disciplinary action taken against

you for misconduct or unsatisfactory service or involved in any court proceedings, if so give details:

Give two references (not related to you) who are well acquainted with your background, service career

and character etc.

Name Occupation Address

Time required to join duty if selected

Minimum gross salary expected in the

position applied for

Rs.

Do you posses a vehicle? Your license no.:

Vehicle registration no.:

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DETAILS OF YOUR FAMILY MEMBERS:

Member Name Nationality

(by birth

and /or by

domicile)

Place of

birth

Occupation (if employed

give Official address &

gross monthly income)

present postal address (if

dead give last address)

Permanent

Home

address

Father (Namein full,

address, if

any)

Mother

Wife/Husband

Brother/Sisters

Any relevant information that you may wish to furnish:

Declaration

I hereby certify that the particulars furnished as above are true, correct and complete in all

respects. I agree and accept without reservation that at any time, if any of the particulars is found

to be untrue, incorrect and/or incomplete, my appointment in the institute may be terminated with

out notice.

Place: Signature of Applicant

Date:

Note: Please furnish full and detailed information under each item and if the space provided in

any column is in sufficient separate sheets may be attached.

For use of P & A only

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FCRI/ADMN/GEN/01

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