FAKIR MOHAN UNIVERSITYVyasa Vihar, Nuapadhi, Balasore, Odisha, Pin- 756089

Phone: 06782-275787/ Fax: 06782-275768Emai1: registrarfmuniversity@gmail.comWebsite: www.fmuniver sity.nic.in

APPLICATION FORM FOR THE APPOINTMENT OF TEACHERS IN THE P.G. DEPARTMENTSOF FAKIR MOHAN UNIVERSITY.

1. a) POSITION APPLIED FOR

b) Advertisement No. & Date

: SUBJECT .

Photo(The entries in this form should be made in English by the candidate)

c) Category (SC/ST/GEN/Persons with disability): .

d) Whether previously applied for this post in response to our Advertisement No

2686 dated 24.4.2018 and No. 3571 dated 5.6.2018: Yes/No

e) If Yes, please provide reference of the Demand Draft already submitted:

Amount: DD No: Date: Bank:

f) Application Fees (Candidates who had applied for this post in response to our Advertisement No

2686 dated 24.4.2018 and No. 3571 dated 5.6.2018 and had paid the requisite fees, they need not pay

the fees again) :

Amount - --------------- vide E-Receipt No and Date or

DD No: , Date , Issuing Bank _

2. Full Name of the Candidatein Block letters (Surname underlined)

3. a) Date of Birth (In figure) .

(In words) .

b) Gender: c) Marital Status: .

d) Nationality: .

4. a) Mother's Name .

b) Father's Name .

c) Mother Tongue .

d) Any other language he/she can:

Read Write Speak .. , ..5. Whether the candidate is qualified the UGC/CSIR NET (give details)

6. Time period taken to acquire the degree(Mention the date, Month & Year):(M.Phil degree: to )

(Ph.D. degree: to )

7. Ifthe candidate has taken any leave for pursuing his M.PhiI.lPh.D. degree during service period:Yes/No

8. If Yes, mention the period and type of leave taken:

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9. Address: Email ID: .

Mobile/Telephone No: Mobile/Telephone No:

Present Address Permanent Address

10. Qualifications in ascending order (one copy of all documents).SI Examinations/ Degree Name of the Division/ Percen Subject YearNo. from Matriculation or University or other Class tage of of Passing

equivalent onwards examining body marks(Specify Hons. /Distinction)

.

11. Field of Specialization:

i) Master's Degree stage

ii) M. Phil Stage .

iii) Doctoral Degree Stage .

iv) Post-Doctoral Research Stage: .

12. Research Publications: (Applicants for Associate Professor should submit three best papers andapplicants for Professor posts should submit copies of five best papers published in peerreviewedlUGC listed journals.

a- Details of research paper published in:I) National journals (Peer reviewed): .(UGC listed, the number in the list may be provided): .

II) International journals (Peer reviewed): .(UGC listed, the number in the list may be provided): .

III) Chapter in books (With ISSN/ISBN Number):

b) Details of books authored/edited(With ISBN Number) and names of all authors:

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c) Number of candidates supervised for Research Degree (M. Phil.lPh. D/D.Sc'/D. Litt)(Provide the list of candidates with year of award of Degree and copies of notificationsof the University)

Degree Awarded(With title of thesis)

Thesis Submitted(With title of thesis)

i)M. Phil .ii)Ph.D .iii)D. Litt.ID.Sc .

d. Details of MajorlMinor research project and amount of the grant received as PI/Co-PI(mention the funding agencies and project sanction letter) of those projects:

e) Details of the seminar/conference attended and presented papers:Invited/oral/poster (Provide list/Certificate to be produced along with Research Score proforma):Mention Chronologically with title of the paper presented, mode of presentation, venue and Data oftheConference / Seminar, National/International/State Level/Regional)

13. If appointed, when can the candidate join the Post: .

14. Membership or fellowship of learned societies or Accredited bodies(Give details) : .

15. Present scale of pay : Rs

Pay Band AGP D.A. H.R.A Any other allowances Total Emoluments

16. Teaching Experience (Experience certificate clearly indicating the period and the level ofteaching,

i.e. P.G., Hons., Pass, etc to be attached)

SI Name of the Design- Nature of the Classes Taught Period Length of experienceNo. College / action Post (Give dates

University (Temporary/ UG PG supporting Years monthsPermanent/ Level Level of joiningAd-hoc) (Pass / and

Hons.) Relieveorder)

.

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17. Other experiences f employments

SINo. Name of post f Date of Date leaving Salary (scale of pay Name & address of theniversity f joining and present basic pay) employerlnsti tution

18. J) Have you ever been subjected to any disciplinary action as a student and for as an employee?11)Have you ever been dismissed fsuspended from service?

19. Any other information in your support:

20. List of documents submitted with the application:1.

2.3.

4.

5.6 .

7.

8.9.

10.11.

Declaration

I, solemnly declare that the entries made in this form are true to the best of my knowledge and belief.

Date: .

Place: . Signature of the Candidate (in full)

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