FOR OFFICE USE ONLY

No. -------"------------------------------------------------------------------------Date-------------------------------------------------------------------------------

APPLICATION FORM FOR SENIOR RESEARCH FELLOWS

Affix Latest coloured Passport size photograph

Name of the post --------------------------------------------------------------------

Advertisement No. ------------------------------------- Serial No. of post -------------

1. Name infull (inblockletters)-------------------------------------------------------
   
   
2. Father's/Husband'sname -------------,...--------------------------------------------
   
   
3. Address:
   
   

(i) Present address (forcorrespondence):

E-mail address ---------------------------------Mobile No. -----------------------

(ii) Permanent home address : ----------------------------------------------------

1. Date of birth -----------------------------------Age -------------------------------(AccordingtoMatriculationCertificate)(EncloseCopy) (Ason ------------)
   
   
2. Are you a bonafide resident of Chhattisgarh Yes/No (If"Yes" pleaseattacha copyof DomicileCertificate)
   
   
3. Placeofbirth(withnameofVilIage/City, DistrictandState) ----------------------------
   
   
   1. (a) Mother tongue -----------------------------------------------------------
      
      
   2. (b) Other language (s) which the applicant can speak, read and write fluently --------
4. Category (UR-UnReserved/SC-ScheduledCaste/ST-ScheduledTribe/OBC-OtherBackwardClasses)
   
   

"f

--------------------------------------------------,

(ifbelongto SC/ST/OBC Category,pleaseenclose a certificatefrom competentauthority)

9. What the applicant is married? (Yes/NO)

(a)

If you are married, marriage date

(b)

The number of children living

(c)Ifyouhavemorethantwosurviving childofthelastchild birth ------------------------------------

9. IfyouareDisabled,Typeofdisability (Pleaseencloseacertificatefromcompetenta~thority)

(a)

Asthibadit

(b)

Vision impaired: -------------------------------------------------------------------------------------

(c)

Deaf

15.Additional Remarks, Ifany: ---:--------------------------------------------------

-

DECLARATION

I declare that the entries made in this applicatiop form are true and correct to the best of my knowledge and belief. .t

Place ----------------------Date ---------------------------Signature of the candidate

REMARKS OF THE PRESENT EMPLOYER

(in the case of those who are already in service)

The applicant Shri/Ku.lSmt./Dr. ------------------------------------------------------is holding a permanent/temporary post of -----------------------------------in the scale of pay , ------------------------------------------------and his/her present basic pay is

, -------------------per month. His/Her application is forwarded and he/she will be

relievedincase he/sheisselectedforthepostappliedfor.

Place ----------------------Date ----------------------Signature Designation of Officer (with official seal)