National Institute of Electronics & Information Technology,

Chandigarh, Extension Centre, Shimla

Hotel Cedar wood Building, Jakhoo Road, Shimla 171001
Performa Application Form
(To be filled in capital letters)

Affix Passport
Size
Photograph
Here

(For office use only)

Verified By: _________________
(Signature)

Post Applied For

: ________________________________________________________

Post Preference in HP (Location):

*Registration Fee (Cash/DD)

1.

2.

3.

: Amount: _________Receipt No. __________Receipt Date: _________

DD No. ______________ DD Date: ____________
Bank Name: _____________________________________________

Name of the Candidate

: ________________________________________________________

Gender

Fathers Name

: ________________________________________________________

Male

Female

Date of Birth (DD/MM/YYYY): _______/_______/___________

Address for Correspondence

: ________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Email-Id

: ________________________________________________________

Contact Telephone No.

(Landline with STD code)

: ________________________________________________________

Mobile Number

: ________________________________________________________

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Educational Qualification 10th class onwards (Attach copies of certificates):

Sr. Qualification/Degree/Diploma
No.

Name of University/Institution

Year of
Passing

%Age/
Grade

Computer Skills:

Brief Description of Experience:

Sr. Name of Organization Worked in
No.

Duration Brief Description of duties

Experience in years & months: ________________________________________________________

Verification:i)
Certified that all the information furnished above by me is correct to the best of my knowledge.
ii)
Certified that I am not involved in any criminal activity and no criminal case is pending against me
in any court of law in India. If at any time it is found that the above information is incorrect, my
services are liable to be terminated without any notice.
(Note: Please write your name in CAPITAL letters on the backside of the bank draft)
--------------------------------------------------------------------------------------------------------------------------------*The registration fee is non refundable.
Place:
Date:

Signature of Candidate

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