BIRLA INDUSTRIAL & TECHNOLOGICAL MUSEUM

Advertisement No. : 02/2015
Name of the News paper :
___________________________________
Space for
affixing
Passport size
recent
Photograph
DHENKANAL SCIENCE CENTRE
(National Council of Science Museums)
Near Rajbati, Dhenkanal – 759 001
************************************************
Form of application for the post of Education Assistant ‘A’ (Pure Science)
D.D. No._______________________ and Date_____________ Amount ___________
Name of the drawee Branch ______________________________________________
( To be filled in by the candidates with own handwriting and forwarded to the above address )
--------------------------------------------------------------------------------------------------------------------------01. Name in full (in block letters) :
-------------------------------------------------------------------------------------------------------------------------02. Address in full :
Present :
Permanent :
Email ID :
--------------------------------------------------------------------------------------------------------------------------03. a) Date of birth
:
( in Christian era )
b) Place of birth
:
--------------------------------------------------------------------------------------------------------------------------04. Are you
YES / NO
* a) a citizen of India by birth and/or by domicile ?
b) a person having migrated from Pakistan or Bangladesh
or other countries with the intention of permanently
settling in India ? or subject of Nepal or Sikkim ?
* Answer ‘Yes’ or ‘No’ and cancel the words, which are not applicable.
--------------------------------------------------------------------------------------------------------------------------05. Name of the State to which you belong :
---------------------------------------------------------------------------------------------------------------------------
:
2
:
06. a) Father’s Name :
b) Address
c) Occupation
:
:
d) Mother’s Name :
e) Address
:
f) Occupation
:
( If dead, state his/her last address and occupation before death )
-------------------------------------------------------------------------------------------------------------------------07. Is or was your father/mother :
(a) a citizen of India by birth and/or by domicile ?
(b) a person having migrated from Pakistan or Bangladesh or
other countries with the intention of permanently settling
in India or a subject of Nepal ?
* Answer ‘Yes’ or ‘No’ and cancel the words, which are not applicable.
-------------------------------------------------------------------------------------------------------------------------08. State your
(a) Religion :
(b) Are you a member of Schedule Caste or Tribe or
Other Backward Class ? Answer ‘Yes’ or ‘No’.
If the answer is ‘Yes’ indicate caste.
:
(c) Are you physically challenged? If yes, give details :
(d) Are you an Ex-Serviceman? If yes, give details :
---------------------------------------------------------------------------------------------------------------------------09. Particulars of all examinations passed and degrees and technical qualifications obtained
at the university or other places of higher technical education (commencing with the
Madhyamik or its equivalent examination).
Examination or Degree
or Diploma
Name of
Board/University
Class or
Division
Subjects taken
Year of
passing
: 3 :
---------------------------------------------------------------------------------------------------------------------------10. Any additional qualifications such as membership of Scientific Societies may be
mentioned here.
---------------------------------------------------------------------------------------------------------------------------11. Have you been outside India/If so, give following particulars :
Country visited
Date of visit
Duration of visit
Purpose of visit
12. If you are/were a full time researcher, give the following particulars :
Name of the
Institution
Date of
joining
Date of
leaving
Area of research
Stipend/
Scholarship
No. of
papers
published
13. What language (including Indian language) you can read, write or speak.
Give particulars and state any examinations passed in each.
Read only
Speak only
Read and speak
Read, write and
speak
Examination passed, if
any
14. Details of previous employment :
Name of
Organisation
Date of
joining
Date of leaving
and reasons
therefore
Designation and
Nature of work
Salary and Grade
:
4
:
15. Are you employed in a Govt./Autonomous organization
at present ? (Answer ‘Yes’ or ‘No’) If yes, state whether
your appointment is temporary or permanent.
---------------------------------------------------------------------------------------------------------------16. Are you willing to accept the minimum initial pay offered ?
If not, state what is the lowest initial pay that you would
accept in the prescribed scale.
--------------------------------------------------------------------------------------------------------------17. If selected what notice would you require before joining
Immediate/One month/Two months/Three months
---------------------------------------------------------------------------------------------------------------18. Have you any relative working in the NCSM ? If so,
please give details.
---------------------------------------------------------------------------------------------------------------19. Are you willing to work anywhere in India ?
( Answer ‘Yes’ or ‘No’ )
---------------------------------------------------------------------------------------------------------------20. References :
(They should be residents in India and holders of responsible positions. They should be
intimately acquainted with the applicant’s character and work but must not be relations.
When the candidate has been in employment, he should either give his present or most
recent employer or immediate superior as referee or produce testimonial from him in
regard to the candidate’s fitness for the post for which he is an applicant)
(i)
Name
:
Occupation or position :
Address
:
(ii)
Name
:
Occupation or position :
Address
:
(iii)
Name
:
Occupation or position :
Address
:
:
21. In Case of Ex-Serviceman
a) Pension Payment Order No.
:
b) ECHS Card No.
:
22. PAN /AADHAR no. if any,
:
5
:
-------------------------------------------------------------------------------------------------------------------------Note :
1. Information in respect of Columns 3a, 8b, 8c, 8d, 9, 14, 21& 22 should be supported by
attested copies of certificates and testimonials, otherwise the application will not be
considered
2. Canvassing in any form and/or bringing in any influence political or otherwise, will be
treated as a disqualification for the post.
-------------------------------------------------------------------------------------------------------------------------I hereby declare that the information furnished in this application is true & correct to the best
of my knowledge and belief.
Date :
Candidate’s signature_____________________________________
(Telephone No., if any :
Candidate already employed should get the following endorsement signed by his/her present
Employer.
ENDORSEMENT BY THE PRESENT EMPLOYER (if he/she is Govt. employee)
Date______________________________________
Name_____________________________________
Full signature ______________________________ with seal
File No._______________________