RANI CHANNAMMA

UNIVERSITY, BELAGAVI

APPLICATION FORM Notification: Post Applied: Subject: Application No: Personal Details Name Father’s Name Mother’s Name Affix Photo here Age Marital Status Category Religion Mobile No.

Date of Birth Place of Birth Gender Nationality Phone No. Email Address Address for Correspondence Permanent Address

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Languages Known Language

To write

To read

To speak

Educational Details Sl. No. 1

Degree/Course

2

3

4

5

* Note: SSLC Onwards

Board/University

Year of Passing

Max. Marks

Marks Secured

Percentage of Marks

Division

Subject Studied

Educational Details (M.Phil and Ph.D) Sl. No.

Degree

1

M.Phil

2

Ph.D

Date of Registration/ Admission

Details of JRF/NET/ SLET/PDF NET – JRF NET SLET PDF

Date of Submission

NET/SLET Subject

Date of Award

University/ Institute

Title of Thesis/ Dissertation

Certificate No. / Roll No.

Year of Passing

Overall %

State

Full-time Teaching Experience Sl. No.

Name of University/ College/ Institute

Designation

Name of University/ College/ Institute

Designation

Status

Pay Scale/ Consolidated salary

From

To

Enclosure No.

1 2 3

Full-time Post-Ph.D Research Experience Sl. No.

Pay Scale/ Consolidated Salary

From

To

Time Period

1 2 3

Present Employment Details Organization Name

Position Held

Date of Appointment

Present Status

Enclosure No.

Research Papers Published (Approved by UGC) Sl. No.

Publication Type (National/ International)

Title of the Paper

Journal Name

Year

Vol. No.

Page No.

ISSN/ ISBN No.

Journal No. given by UGC

Author/s

Impact Factors if any

Enclosure No.

1 2 3

Publications other than journal articles (books, chapters in books) Sl. No.

Publication Type

Title of the Book

Title of the Paper

Year

Page No.

ISSN/ ISBN No.

Publisher Details and Address

Author/s

Enclosure No.

1 2 3

Research Papers Published (Not Approved by UGC) Sl. No.

Publication Type (National/ International)

Title of the Paper

Journal Name

Year

Vol. No.

Page No.

ISSN/ ISBN No.

Author/s

1 2 3

Other Details Sl. No. 1

2

Name

Yes/No

Details

Were you at any time declared medically unfit or asked to submit your resignation or discharges or dismissed? If yes, give details. Do you have any criminal case pending against you in a court of law? If yes, give details.

Other activities/Responsibilities if any, not listed above (not more than 500 words)

Enclosure No.

Two References familiar with your academic work Sl. No.

Full Name

Institutional Affiliation (Present/Former)

Designation

Address

Mobile/Phone No.

Email Address

No Objection Certificate No objection certificate (if applicable)

Application Fee Payment Details Name of the Bank

Name of the Bank Branch

DD No.

DD Date

Amount (in Rs.)

Declaration I ____________________ son/daughter of ___________________ declare that all the entries made by me in this application are true and correct to the best of my knowledge. If anything is found false or incorrect at any stage, my candidature/appointment may be cancelled by the University without any reason thereof.

Date: Place:

Signature of the applicant