INDIAN INSTITUTE OF TECHNOLOGY KANPUR KANPUR The Office of Dean, Research and Development

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1 INDIAN INSTITUTE OF TECHNOLOGY KANPUR KANPUR The Office of Dean, Research and Development Application No.: (For Official use) Advertisement No. : REO/R&D/2019/01 Serial Number : Post Applied for : Post Code : Cadre: Department : Affix selfattested passport size recent color photograph Particulars of D.D. No.:.... Date:.... For Rs.:..... Drawn on.. Bank For Official use D.D. for Rs... Removed Date:.... Signature 1. Applicant Name (In BLOCK LETTERS): First Name Middle Name Last Name 2. Father s/husband s Name: First Name Middle Name Last Name 3. Mother s Name: First Name Middle Name Last Name 4. (a) Date of Birth (DD/MM/YYYY): / / (b) Place of Birth: (as per 10 th certificate) 5. Nationality: 6. Gender: 7. Aadhaar No.: 8. Address: (a) Present (Mailing Address) (b) Permanent Phone/Mobile Phone/Mobile 1

2 9. Age as on the date : Years Months Days 10. Category (attach a self-attested copy of the certificate from the authority prescribed under Govt. rules, if applicable) (Tick mark in appropriate box): SC ST OBC GEN PWD 11. Are you related to any employees of the IITs: Name Designation Name of the IITs/ department where working Relationship 12. Education qualifications (matriculation/ 10 th onwards, in reverse chronological order): (Please attach self-attested copies of certificates) Examination passed Board/ University Total Marks Marks secured % of marks Class/ Division Year of Major Subjects/ Duration passing Specialization 2

3 (For more details use separate sheet) 13. Awards and Recognitions: ( For more details use separate sheet) 14. Any other relevant information: 15. Details of professional experience (Start from present Employer) (attach self-attested copy): Name of the Employer Post held Scale of Pay & last gross salary drawn/ Consolidated Salary (Rs.) From Duration To Experience In Month Nature of Job 3

4 (For more details use separate sheet) 16. Total Experience: year(s) month(s) 17. Salary/ Total Emoluments Expected at IIT Kanpur: 18. Area of Specializations: 19. Current Area of Research: 4

5 20. Details of Publications/patents, if any (attach reprints): Scientific Journals National International Total: No. of patents filed and granted No. of papers Published Accepted Communicated 21. Whether visited outside India? If so, particulars thereof: Name of Country Visited Duration of Visit From To Purpose of visit Passport No. & Date (For more details use separate sheet) 5

6 22. Names and Addresses including , Fax, Tel.No., of Three Referees (at least one of them should be familiar with your work): Referee -1 Referee - 2 Referee Contact No.: Fax No.: Contact No.: Fax No.: Contact No.: Fax No.: 23. List of enclosures: 6

7 DECLARATION I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. In the event of the information being found false or incorrect or any ineligibility being detected before or after the selection, my candidature is liable to be cancelled and action initiated against me. Date: Place: Candidate s Signature Candidate already employed should get the following endorsement signed by his/her present employer. ENDORSEMENT BY FORWARDING AUTHORITY No. Date: 1. In case of selection, the candidate will be relieved within one month of the receipt of appointment letter. 2. No Vigilance enquiry is pending against Mr. / Ms.. Full Signature Designation (Seal) 7