ALAGAPPA UNIVERSITY

(A State University established by an Act of the Govt. of Tamil Nadu)

(Re-accredited with A Grade by NAAC)

KARAIKUDI 630 003

Advertisement No.Appt./02/2012, dt.06.07.2012 Application for the Post of ___________________________
(Please indicate the Sl.No. and Name of the Post as advertised) Affix Recent Passport size colour photograph

No.

Demand Draft for Rs.____________ DD No.____________ Date ____________ Bank __________________________

1.

Name in full (in BLOCK letters)

2.

(a) Age and Date of Birth (b) Place of Birth and District

3. 4. 5.

Sex Nationality and Religion Community (Certificates must be enclosed for BC/MBC/DNC/SC/SCA/ST)

Male

Female

OC

BC MBC DNC

SC

SCA ST

6.

Whether the applicant belongs to Persons With Disabilities (PWD) category If yes, please specify
(Certificate obtained from competent Medical Authority should be attached as evidence)

Yes

No

Disability (%) i) Visually Impaired ii) Hearing Impairment iv) Others, if any ___________ ___________ ___________

iii) Orthopaedically Handicapped ___________

7.

Permanent Address
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Phone/ Mobile: E-mail: 8. Address for Communication

Phone/ Mobile: E-mail: 9. (a) Educational Qualification

Name of the Institution/University Major Subject(s) Regular or Distance or
Open University System

Programme of Study

Month Class % of & Year Marks of (exact - 2 Passing decimals)

Ph.D. M. Phil. PG ______ UG ______ HSC SSLC Others, if any 9. (b) Details of Qualifying Level Test Name of the Qualifying Level Test NET SLET/SET Name of the Institution Subject Month & Year of Passing

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10.

Area of Specialisation

11.

Employment details Designation held Date of Joining Date of Leaving *Salary details (Basic Pay and Allowances)

Name of the University/College/ Institute

*Service Certificate with present Salary details to be enclosed

12.

Teaching Experience

i) Graduate Level ii) Post Graduate Level iii) Others (specify)

years years years

13.

Research Experience (a) Research Guidance

Total No. of Years __________ M.Phil. Completed Ph.D. Completed Ongoing Ongoing Ongoing

(b) Research Projects (details to be enclosed) (c) No. of Research Publications/ Books (details to be enclosed including ISBN/ISSN Nos.) 14. Administrative Experience (Give details)

Completed

years

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15.

Any other experience that can be counted Participation in extra-curricular and sports or athletic activities during your educational career Languages known (Please underline your mother tongue) Speak only Read and Speak Read, Write and Speak Examination passed, if any

16.

17.

Read only

18.

Any Special Programmes attended (give details)

19.

Membership of Academic or Scientific Bodies

20.

Travel Abroad Duration of Visit Month & Year Purpose of Visit

Countries Visited

21.

Prizes, Awards, Special Achievements, if any The period of time required to join the duty, if the post is offered
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22.

23.

Have you ever been dismissed/suspended from service/employment? If yes, give full deails Were you involved in any criminal case? If yes, give full details Is any criminal case pending against you in the court? If yes, give full details

24.

Any additional information that the applicant may wish to be considered Copies of Testimonials (from persons under whom the applicant has studied or worked) Name Designation Address

25.

1. 2. 3.

26.

References (Should be persons in responsible positions who are intimately acquainted with the applicants character and work, but not relations) Name Designation Address

1. 2. 3.
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25. Enclosures (in the following order):

i)

ii) iii)
iv) v)

vi) vii) viii) ix) x) xi)

First page of SSLC Book/Transfer Certificate HSC Mark Statement Degree Certificates starting from highest degree Mark Statements for PG Degree(s)/M.Phil. NET/ SLET/ SET Certificate(s) Community Certificate, if applicable Service Certificate from the present employer Copies of certificate(s) for previous employment List of Publications Copies of Testimonials Others

I, ________________________________ hereby declare that the information given in this form are true to the best of my knowledge and belief. I also understand that suppression of facts or deliberate furnishing wrong information will entail summary rejection of application and, if detected after appointment is made, lead to disciplinary action or termination of appointment. Place: Date: Signature of Applicant

REMARKS OF FORWARDING AUTHORITY

Place: Date : Signature with Seal

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