INDIAN INSTITUTE OF MANAGEMENT TIRUCHIRAPPALLI

NIT Campus (Post), Thanjavore Road, Thuvakudi, Tiruchirappalli 620 015 Tamil Nadu, INDIA Phone: +91 431 2501122 / 21 E-mail: director@iimtrichy.ac.in Web: www.iimtrichy.ac.in FORM-II APPLICATION FOR THE POST OF ___________________________ Affix your recent passport size colour photograph

1. Name (in CAPITAL letters) ____________________________________________________________ (FULL NAME) 2. Name of Father/Guardian/Husband: 3. Date of Birth: DD ________ MM _______ YY _______ (Proof to be enclosed) 4. Nationality: 5. Gender (Male / Female): 6. Marital Status:

Age: ____________

7. Category: GEN / SC / ST / OBC / PHC / Others (Specify) __________________________ (Proof to be enclosed) 8. Address: Communication Address: Permanent Address:

Email: Telephone: Mobile: 1

Email: Telephone: Mobile:

9. Academic Qualifications (Proof to be enclosed): (additional sheet may be used, if required) Name of Degree / Diploma / Certificate School / College / Board / University Year of Passing Marks/Grade & Class obtained

10. Language Proficiency: (Please tick relevant cells) Language English Hindi 11. Technical Skills: (Please tick relevant cells and attach copies of certificates) Skill Computer Operations Database Applications 10-Finger Typing English 10-Finger Typing Hindi Shorthand English Any Other Skill 2 Excellent Good Average Weak Nil Fluent in Speaking Fluent in Reading Fluent in Writing

12. Employment details (Proof to be enclosed): (additional sheet may be used, if required) Organization & Location Position Held Date of Joining Date of Leaving Salary Drawn

Total experience: __________ Years _________ Months

13. References: (Please give names of three referees with address and contact numbers)

DECLARATION I hereby declare that the particulars furnished above by me are true and complete to the best of my knowledge and belief. I understand that if any particulars found to be false at a later date, my candidature shall be liable to be cancelled without assigning any reason. Place: Date: SIGNATURE OF THE APPLICANT