Indian Institute of Technology Indore

Application for Academic Appointment

Affix a
passport size
color
photograph

Date of Application: _________________________________

Post Applied for:
_________________________________
Discipline:
_________________________________
1. Name:
First Name

Last Name

2. Personal Details:
a) Date of Birth: __________________
(dd/mm/yyyy)
b) Age:
___________________
(in years)

Middle Name

c) Gender:
________________
d) Marital Status: ________________
e) Nationality:
________________

3. (a) Contact Address:

__________________________________
__________________________________
__________________________________

(b) Permanent Address:

__________________________________
__________________________________
__________________________________

4. Contact Details (with STD/ISD code):

a. Phone (Office): _______________
b. Phone (Res): _________________
c. Mobile:
_________________

d. Fax: __________________________
e. E-mail ID:
______________________________

5. Academic record starting with school leaving exam:

(Please attach photocopies of transcripts/ mark sheets/ grade card and certificates for all your
degrees):
Specialization
/ Discipline

College/University/Institute

Year of
joining

Year of
leaving

Percentage
/ CGPA

6. Areas of specialization: ____________________________________________________

_______________________________________________________________________
7. Current area of research: ___________________________________________________
________________________________________________________________________
8. Present employment:
Designation
Organization
Date of joining (dd/mm/yyyy)
Scale of Pay in Rs
Pay in Rs.
Total Emoluments (per month) in
Rs
9. Basic Pay expected at IITI as per advertisement, Rs. ___________________________
10. Information of three Referees:
(Names and contact details of referees who would be willing to write in support of your application):
Referee 1

Referee 2

Referee 3

Name
Designation
Organization/
Institute
Address Line
1
Address Line
2
Address Line
3
Telephone
E-mail i.d.
11. Please tick the appropriate box:
(Please attach a certificate from the authority prescribed under government rules for SC/ST/OBC)
General

SC

ST

OBC

12. I hereby declare that I have carefully read and understood the instructions and particulars supplied to
me, and that the entries in this form as well as in attached sheets are true to the best of my knowledge
and belief.
There are ___________ sheets attached along with this form.

Date:
______________________________
Place:
(Signature of Applicant)
PROVIDE THE FOLLOWING INFORMATION WITH THE APPLICATION: (Indicate "NIL" if
required; DO NOT omit/delete the following points. Your application may not be processed in the
absence/incompleteness of the following information)
Note:
i. For items a throughs, use separate sheet for each sub-heading in the format indicated.
ii. All annexure should be consecutively arranged and must bear your name.
a) List of publications:
List those PUBLISHED, ACCEPTED, and IN PREPARATION separately
a. Papers in refereed journals (Please also include the journal impact factor)
b. Papers in conference proceedings
c. Papers presented in conferences but not published
d. Books/Chapters in books
Please enclose reprints of maximum of three papers which in your judgment are your best.

b) Employment history:
Sl. No.

Position

Organization/Institution

Date of
joining

Date of
leaving

Duration

c) Teaching Experience, Courses/Laboratories:

(Indicate any special work done towards developing new course or laboratories)
Sl.
No.

Title of course
taught

Postgraduate/
Undergraduate

d) Research Experience: (including Post doctoral)

Sl.
Position Institute Supervisor Topic
No.

Sole instructor or with

others

Date of
Joining

Year

Date of Duration
Leaving

e) Post Graduate Thesis Supervision:

Name of student/
Title of
Sl. No.
research scholar
Thesis

Doctorate/
Masters

Year of
Completion

Co-guide (If
any)
f)
S

ponsored Projects Undertaken:

Sl. No.

Sponsoring Agency

Sl. No.

Organization

Title of
Project
Title of
Project

Amount of
grant
Amount of
grant

Period
Period

Co-investigator
(If any)
Co-investigator
(If any)

g)
C

onsultancy Work Done:

h) Industrial Experience Interaction:
Sl. No.
Organization

i)

Nature of Work

Period

Professional Training Received:

Sl. No.

Name of Training

Organization where training was

received

Year

Duration
j)
M

embership of Professional Bodies/Organizations:

Sl. No.

Name of the Professional Body

Membership Status
(Life/Annual)

k)
I

mportant Conferences/Seminars Attended:

Sl. No.

Conference/Seminar

Title of paper read (if any)

Year
l)

Contributions (teaching) to Continuing Education Programs

m) Short-term Course/Workshop/Seminars etc. organized

n) Other academic and corporate activities

o) Awards and recognitions

p)

Please list the type of undergraduate/postgraduate courses that you will like to develop and/or teach
at IIT Indore (attention is drawn to our UG and PG courses). You may additionally include the
courses that you may like to develop at IIT Indore.

q) Please attach a brief statement (less than 2 pages) on your immediate short-term research plans (2-3
year time frame). Additionally, please also include the research facilities (equipment, space, funds,
manpower) that you will need for your research work.
r) Please write briefly why you wish to be considered for a faculty position at IIT Indore and how do
your long-term career objectives tie in with a position at IIT Indore? Briefly, also write about how
you propose to contribute to IIT Indore, and how the Institute can help for your best possible
professional growth (300 words).

s) Any other relevant information you may like to furnish