Application form

ODISHAUNIVERSITYO
OFAGRICULTURE&TECHNOLOGY
Bhubaneswar-751003,Odisha
APPLICATIONFORM
Affixsigned
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No.Applicationf …………………….. /UAT, dated.………………… photographs

postof……………………………………………..
ortheDiscipline
……………………………………………………
:………… DETAILSOFBANKDEPOSIT
1. NameoftheBank…………………………………………………………… …….
2. Amount(Rs.)………………….(Rupees .................................................................)only
(attachedoriginalcounterfoilofrequiredamountdulysignedbythecandid
ateinsupportofevidence)
PERSONALHISTORY
(1) FullNameofthecandidate : ……………………………………………………
(inblockcapital)

(2) Addressforcommunication (3) Permanentaddress

………………………………………………. …………………………………………………….
………………………………………………. …………………………………………………….
………………………………………………. …………………………………………………….
Pin- Pin-
Telephone:…………………………………. Telephone:……………………………………..
Mobile:……………………………………… Mobile:…………………………………………..
E-MailID:………………………………….. E-MailID:……………………………………….
(AnychangeofaddressshouldbereportedinwritingatoncetotheRegistrar,OUAT,Bhubaneswar)

(4) Dateofbirth(AsrecordedintheICSE/CBSE/HighS : …………………………………………………..

choolCertificate)

(5) BirthPlace:………………………………….
HomeState:……………………………….. HomeTown:……………………………………
(6) Nationality: ……………………………………………………
(7) Sex:(Male/Female)……………………… (8) Mothertongue:………………………………..
(9) MaritalStatus:Single………………Married………………….Widow(er)……………………….
(IfMarriedwhetherhehasgottwowives)
(10) WhetherbelongstoST…………….SC…………SEBC………….PWD………….Other………..
(AttachedauthenticateCasteCertificatefromthecompetentauthority)

(11) LanguageKnown
LanguageProficiency Speak Re a d Write
 -: 2:-

(12) Anymedicaldisability(pl.Specify) : …………………………………………………….

(13) Father’s/Husband’sName, : …………………………………………………….

occupation/andaddress …………………………………………………….
(14) Educationalqualification:
Division/ Field
NameoftheE NameofBoard/Un percent/ ofspecialization Year Yearof SubjecttakeninH
xamination iversity Finalgr ofjoini passing ons/distinction
Major Minor
ade/ ng
(i) Matriculation

(ii) Intermediate

(iii) BachelorDegree

(iv) MasterDegree

(v) M.Phildegree

(vi) Ph.D.degree

(vii) N.E.T.

(viii)

Photocopiesofcertificates&transcriptsmustbeattachedinsupportofevidenceforconsiderationofcandidature.
(15) Publications:(AttachlistofPublications)
Particulars No.ofArticles/Bookletpublished
(a) ResearchpaperpublishedinInternationalJour :
nal
(b) ResearchPaperpublishedinNationalJournal :

(c) Populararticlesandbooklets. :

(d) Books/manuals. :

Note:ThepublishedarticlesanddulyacceptedarticleswithletterofacceptanceandManuscriptaretobeincludedonlyandnotarti
clessentforpublication
(16) Medals/Awards
Yearinwhichre Nameoftheorgani
Particulars NameoftheMedals/Awards
ceived zation
(i) Awardedonacademica
chievements
(ii) Awardedforscientificcont
ribution
(17) Seminar/Symposium/Workshop/Summe/WinterInstituteattended(Attachcertificate/documents)
Particulars Numberattended Duration(days)
(a) Seminar
(b) Symposium
(c) Workshop
(d) Summer/winter institute
 -: 3:-

(18) Project(s)conductedandon-goingproject
Particulars Detailsofproject/researchscheme
Project/scientificresearchschemeconducted :
onthebasisofpersonalbio-
datathroughtheinstitutionlikeICAR/
CSIR/UGC&otheragencies.
Note:Ifmorespaceisrequired,pleasegivedetailsinseparatesheetgivingnumber

(19) Membership
Particulars(Membersin) De t a i l s
(a) Scientific/Govt.Board/Committee/So
ciety
(b) PanelonEditorialBoardofNationalLevelJournal.

Note:Ifmorespaceisrequired,pleasegivedetailsinseparatesheetgivingnumber

(20) Experience(EmploymentRecord)
Experienceregardingpreviousandpresentemployment(Attachthecertificate/orders,ifany)
Reasonf
Nameandnatureofpostorappoi Date Date Salarydr Employer’sname orleavin
ntmentof ofjoini ofleavi awn(Basi andaddress g
cPay)
ng ng service

(21) Abstractofexperience
Particulars Year Mo n t h days
(a) Experience below Assistant Professor and
itsequiv.cadreinresearch&extension
(b) Experienceinthecadreof
Assistant
Professoranditsequivalentcadreinresearch
&extension

(22) Totalteachingexperience
Undergraduateteaching

Postgraduateteaching

.
(23) AnyotherworkdonesinceleavingCol
legewithdate.
 -: 4:-
(24) ExtraActivity
Particulars Placewhereyouhaveworked No.ofdays
(a) Chairman/Ex-
Officio/AdministrativeHead
(b) Warden/Asst.Warden
© MembersofcommitteesofUniversity/
College
(d) StudentAdvisoryBoardofFaculty

(e)
NCC/NSSOfficer

(25) ForeignCountryvisited(ifany)
Periodofvisit PurposeofVisit
NameoftheCountry
From To (Givecompletedetails)

(26) Givedetails
(a) Distinctionsgainedinschoolorcollege
:gamesandsports.
(b) Presentrecreation,hobbiesandother
:interest(e.g.inthefineartsorin
organizingsocialandpublicwelfare)
(27) Name, address and profession of two (02) referees who should be responsible persons
notrelated to the candidate or connected withhis/her school or college but well acquainted
withhis/herprivatelife.
Period,hehasknownth
Nameofthereferees FullAddressandtelephonenumber
ecandidate
(1)
(2)

(28) Whether,youhavepunished/dismissedorcon : Yes…………………..No…………………..

victedbyanyinstitution/Govt./Court,ifyespleas
egivedetailsonseparatesheet

(29) Ifappointmentisoffered,whencanthe
:candidatejointhepost

(30) Detailsofenclosures: :

DECLARATION
Iherebydeclarethattheinformationfurnishedaboveistrueandcorrecttothebestofmyknowledgeandbelie
f

Place: Fullsignatureoftheapplicant
Date: