Annexure-“C”

THDC INDIA LIMITED (A Joint Venture of Govt. of India & Govt. of U.P.) (A MINI RATNA COMPNAY)

Advt. No. 02/2011

APPLICATION FORMAT (Use Block Letters Only) (Please fill up this form with utmost care)

Post Applied for : ________________

Affix recent passport size color photograph here

Discipline: ________________

UGC-NET-January 2017 Registration No:------------------------------A.

PERSONAL DETAILS: 1. Name (as appears in SSC certificate)

Please put a space between your first name, middle name (if any) and last name. 2. Father/Husband’s Name 3. Date of Birth

DD

MM

4. Age as on 31.12.2016

Yr

Month

YYYY Days

5. Sex (write “M” for Male or “F” for female) 6. State of Domicile 7. E-Mail ID B.

CORRESPONDENCE ADDRESS

City/Town Telephone Number:

State STD Code

Mobile No.

C.

Pin Code Tel. No.

+91

PERMANENT ADDRESS

City/Town Telephone Number:

Mobile No.

State STD Code

+91

Pin Code Tel. No.

Tel. No.

D.

ACADEMIC PERFORMANCE 1.

Exam Passed

Basic Qualification : Start from Matriculation/Higher Secondary Institution/ University/ Board

Subject of Study

Duration of Study

Month/Year of Passing (MMYYYY)

Aggregate % of Marks/ CGPA(*)

Full Time/Part Time/Corres pondence

2.Professional Qualification (Please mention qualification which makes you eligible)

3.Additional Qualification (if any)

(*if it is Cumulative Grade Point Average (CGPA), please convert it to % of Marks) E.

Category

(GEN/SC/ST/OBC/EX-SM)

Are you physically handicapped? (Yes/No) If yes please mention the details as follows: VH Type of handicap (please put (√) in appropriate box)

HH VHVH

OH

Extent of disability as specified in the disability certificate Do you belong to Minority? (Yes/No) F.

Religion

G.

Details of Experience (if any)

Name of Organisation

Designation

Scale of Pay

Duration

Regular/Contract/ daily wage

From To (MM/YYYY) (MM/YYYY)

Post Qualification Experience: Years Total Gross Emoluments

Months

Nature of Duties

Reason for leaving

H.

For Departmental Candidates (THDCIL Regular Employees) Only

(i)

Employee No.

(ii)

Date of Joining THDCIL

(iii)

Position held as on date

(iv)

Date of Joining in Present Grade

(v)

Whether Disciplinary Proceeding pending/contemplated, if any YES/NO If yes, give details:

I.

Languages known

Read

J.

Write

Speak

Other Information Whether under any Service Bond

YES

NO

If yes give details Details of Outstanding Loan (if any) Participation in Sports/Games (if any) National /State/College Level Extra-curricular activities Details of Awards (if any)

Declaration: I affirm that the information given in this application is true and correct to the best of my knowledge and belief. I further undertake that if at any stage it is discovered that an attempt has been made by me, willfully to conceal or misrepresent the facts, my candidature /appointment shall be summarily rejected or terminated without any notice. Date:

Signature

Place:

Name