Institute of Pesticide Formulation Technology (IPFT) : Sector-20, Udyog Vihar, Gurgaon - 122 016 (Haryana)

Institute of Pesticide Formulation Technology (IPFT)
Sector-20, Udyog Vihar, Gurgaon 122 016 (Haryana)
Appl. No.
APPLICATION FORM FOR SCIENTIFIC & ADMINISTRATIVE POSITION
Advt. No. __________________________ Dated ______________
DD No.
Name of Bank
Date of DD
Affix a recent
passport size
photograph
duly attested
by the
candidate
Post Applied For : ______________________________

1.
Name in Full
(In Capital letters)
________________________________________________
2.
Father's / Husbands Name
________________________________________________
3.
Mothers Name
________________________________________________
4.
Name & Occupation of Spouse
________________________________________________
5.
Date & Place of Birth
________________________________________________
6.
Nationality
_______________
7.
Sex (Male/Female)
_______________
8.
Whether belongs to SC/ST/OBC : YES / NO

(If Yes, attach a Certificate from the Authority prescribed under Government Rules)
9.
Are you seeking age relaxation

If so, under which category?
10.
Whether claiming reservation under SC/ST/OBC Category

:
YES / NO
(Please note that the benefit of reservation can only be claimed by the candidate when the post(s)
has been reserved as such and the candidate has furnished the requisite certificate)
11.
Postal Address
_______________
Correspondence Address
Permanent Address
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PIN _________________ Mobile__________________
PIN _________________ Mobile__________________
Phone _______________ Fax ____________________
Phone _______________ Fax ____________________
E-mail _______________________________________
E-mail _______________________________________
12.
Details of Educational Qualifications : Please give particulars of all examinations passed and
degrees obtained commencing with the High School leaving (10th Standard / Matriculation)
Examination. For Ph.D., please give details, even if it is not complete. Please attach self attested
copies of certificates and mark sheets.
Examination / Degree /
Diploma Passed
13.
Year of Passing
Subjects Studied
% of
Marks
Remarks
Details of Employment in Reverse Chronological Order :
Period
From - To
14.
Institution/ University
Designation
Organization
Pay Scale
Basic Pay
Total
Emoluments
Responsibilities
Publications (Enclose reprint of the best papers (only two) in your judgment), if applicable
A.
S.
No.
B.
S.
No.
C.
S.
No.
D.
S.
No.
Papers in Refereed Journals (List those published and accepted separately)

Author(s)
Year
Title
Complete Reference of Journal
Papers Published in Conference Proceedings

Author(s)
Year
Title
Name and Place of Conference
Papers Presented in Conferences but Not Published

Author(s)
Year
Title
Publisher
Books (List those published and in press separately)

Name/Title
Year
Please include an introduction of the book.
Title of Publisher
Author
15.
Awards / Recognitions & Fellowships :

S.
No.
16.
Award Name
Awarding Organization
Membership of Professional Societies / Institutions :

Name of the Professional Institute / Society
17.
Type of Membership
Have you ever been abroad? If so give the following particulars :

Country Visited
18.
Awarded Work / Project
Duration of Visit
Purpose of Visit
Please name two references who are not your relatives (at least one of them must be your
present employer / supervisor) :
Sr. No.
Name & Occupation
Address
Contact No.
E-Mail
1.
2.
19.
Have you ever been convicted by a court of Law or is there any criminal case/disciplinary
action/vigilance enquiry pending / contemplated against you? If yes, specify : _______________
20.
Would you like to treat your personal information in this application with enclosures as
confidential for RTI Act 2005 Provisions (Write Yes or No) : __________________
21.
If appointed, How much time would you require for joining the post ? _________________
22.
Any other relevant information : ________________________________________________

DECLARATION
I hereby declare that I have carefully read and understood the instructions and particulars
supplied to me and that all the entries in this form are true to the best of my knowledge and belief. I also
declare that I have not concealed any material information which may debar my candidature for the post
applied for. In the event of suppression or distortion of any fact like category or educational
qualification etc. made in my application form, I understand that I will be denied any employment in the
Institute and if already employed on any of the posts in the Institute; my services will be terminated
forthwith.
There are enclosures with total of . pages attached along with this form.
Place : ...
Dated : ..
(Signature of the Candidate)
CERTIFICATE TO BE GIVEN BY THE DEPARTMENT

Certified that the particulars furnished by Dr./Sh./Smt.
Designation . have been verified and found correct as per office records.
It is also certified that no disciplinary/vigilance case is pending or contemplated against the official
concerned.
The integrity of the official is also certified.
(Signature of the Head of the Office)

with Designation and Seal

Institute of Pesticide Formulation Technology (IPFT) : Sector-20, Udyog Vihar, Gurgaon - 122 016 (Haryana)

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Institute of Pesticide Formulation Technology (IPFT)

Sector-20, Udyog Vihar, Gurgaon 122 016 (Haryana)

APPLICATION FORM FOR SCIENTIFIC & ADMINISTRATIVE POSITION

Advt. No. __________________________ Dated ______________

Post Applied For : ______________________________

Father's / Husbands Name

Name & Occupation of Spouse

Date & Place of Birth

Whether belongs to SC/ST/OBC : YES / NO

Are you seeking age relaxation

Whether claiming reservation under SC/ST/OBC Category

PIN _________________ Mobile__________________

PIN _________________ Mobile__________________

Phone _______________ Fax ____________________

Phone _______________ Fax ____________________

Details of Employment in Reverse Chronological Order :

Papers in Refereed Journals (List those published and accepted separately)

Complete Reference of Journal

Papers Published in Conference Proceedings

Name and Place of Conference

Papers Presented in Conferences but Not Published

Books (List those published and in press separately)

Please include an introduction of the book.

Awards / Recognitions & Fellowships :

Membership of Professional Societies / Institutions :

Have you ever been abroad? If so give the following particulars :

Awarded Work / Project

Name & Occupation

Any other relevant information : ________________________________________________

(Signature of the Candidate)

CERTIFICATE TO BE GIVEN BY THE DEPARTMENT

(Signature of the Head of the Office)

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Advt. No. ____________ Dated

PIN _ Mobile__

PIN _ Mobile__

Phone _ Fax ______

Phone _ Fax ______