4 Application Form Lecturer Tech - Asst. Librarian

CENTRAL INSTITUTE OF PLASTICS ENGINEERING & TECHNOLOGY (CIPET)
(Dept. of Chemicals & Petrochemicals,

Ministry of Chemicals & Fertilizers, Govt. of India)
Advt. No. CIPET / HO / NP / 01 / 2019
APPLICATION FORM
Note: i) Please read the attached information regarding last date of submission of duly completed application form,
Essential Qualification & Experience and Rules & Regulations before filling the application form.
ii) Please tick ( ) wherever applicable.
1. Post Applied For:

(Choose any one Post) Paste
(i) Lecturer Passport Size
(ii) Technical Assistant Photograph
(Testing / Processing / Tooling & CAD/CAM / Skill Training)
(iii) Librarian
2. Centre applied for :

(Choose any one Centre)
(Centres: Baddi, Chandrapur, Deharadun, Ranchi, Kochi, Korba & Vijayawada)
3. Full Name
(in block letters)
4. Date of Birth Blood Group
5. Community
(SC/ST/OBC/GEN)
(Enclose attested copy of certifcate)
6. Whether Economically Weaker Sections (EWSs) Yes No

(Enclose attested copy of certifcate)
7. Whether Physically Challenged Yes No
If yes, state % of disability

(certificate to be enclosed)
8. Whether Ex-Servicemen Yes No
9. Gender Male Female Others
10. Marital status Married Single Others
11. Nationality Religion
12. Mother tongue

13. (a) Name and Address of Parents
(b) Name of Spouse (if applicable)
(c) If spouse is employed,

Give Employer Name & Place
14. Postal address for correspondence
Tel : Mob :
E-mail :
Nearest Relative’s Mobile Number a)
b)
15. Permanent Address
Place of Upbringing / Hometown:
16. Present employment
Website:
17. Were you at any time declared medically unfit; asked to submit your resignation;
discharged or dismissed from Govt./Semi-Govt./Autonomous Body or Private Service?
If yes, give details in a separate sheet.
18. Have you ever faced any Vigilance Enquiry or enquiry by anti-corruption bureau/Central
Bureau of Investigation or any other Investigative Organization
Yes No
If Yes: Please indicate in brief, the details of the Vigilance Enquiry and outcome thereof
in separate page
19. Academic Qualifications:
(Please attach self attested photocopies of UG/PG Certificates / marksheets)
Give particulars in a chronological order starting from SSLC (Xth Std) School Certificate)
Pass Duration of
Mode of study Division % of Course
Name of Course /
S. Subject/ Full Time / (Ist or Marks/ (whether 1 Year of
Degree /
No Specialization Part time / IInd or CGPS yr. or 2 yrs. Passing
University / Board
Correspondence IIIrd) or 3 yrs.
Class course
4
20. Professional Qualification (e.g. Professional Training, Courses, Workshops etc.)
(Enclose as a separate sheet)
21. Employment details: (Details in chronological order, starting with present employment
upto the first employment
Position Pay Period of Place /

Name & Address of Nature
Sl. held / Scale & Employment state of
Organization / of
No. Designatio Gross (Month/Year) employ
Employer Duties
n Salary ment
From To
* Enclose separately if required
22. Details of your Ph.D Thesis (If applicable)
(Enclose abstract of Thesis)
Sl.
Degree Title of Thesis University
No.
01. Ph.D.
23. Please furnish details regarding Experience, Job Description

(Use a separate sheet if required)
24. Reference
Responsible persons not related to the applicant but closely acquainted with the applicant
Name and Designation Address

1.
Mob:
Email:
2.
Mob:
Email:
25. Notice period / No. of days likely to be availed for relieve from parent organization on
selection:
26. (a) Details of relatives working at CIPET, if any :
(b) Any other information you may like to furnish to CIPET:
27. Social / Political / Religious Affiliations of the Candidate if any, Mention the name and
clear details about the affiliations:
28. Copies of documents enclosed:
i.
ii.
iii.
iv.
v.
---------------------------------------------------------------------------------------------------------------------------
DECLARATION
I declare that the Entries made in the Columns of this proforma are correct and true to the
best of my knowledge and nothing has been either concealed or misrepresented by me. In
case of any misrepresentation, I understand that employment if any gained, is liable for
termination.
Place: Signature
Date:
---------------------------------------------------------------------------------------------------------------------------
N.B.: 1). Use separate sheets wherever necessary while filling application form above.
2). All entries in this application form shall be neatly typed / written.

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CENTRAL INSTITUTE OF PLASTICS ENGINEERING & TECHNOLOGY (CIPET)

(Dept. of Chemicals & Petrochemicals,

Advt. No. CIPET / HO / NP / 01 / 2019

1. Post Applied For:

2. Centre applied for :

4. Date of Birth Blood Group

6. Whether Economically Weaker Sections (EWSs) Yes No

7. Whether Physically Challenged Yes No

If yes, state % of disability

8. Whether Ex-Servicemen Yes No

9. Gender Male Female Others

10. Marital status Married Single Others

11. Nationality Religion

12. Mother tongue

(b) Name of Spouse (if applicable)

(c) If spouse is employed,

14. Postal address for correspondence

Nearest Relative’s Mobile Number a)

15. Permanent Address

Place of Upbringing / Hometown:

16. Present employment

If yes, give details in a separate sheet.

19. Academic Qualifications:

(Please attach self attested photocopies of UG/PG Certificates / marksheets)

(Enclose as a separate sheet)

Position Pay Period of Place /

* Enclose separately if required

22. Details of your Ph.D Thesis (If applicable)

(Enclose abstract of Thesis)

23. Please furnish details regarding Experience, Job Description

Name and Designation Address

26. (a) Details of relatives working at CIPET, if any :

(b) Any other information you may like to furnish to CIPET:

28. Copies of documents enclosed:

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