INDIAN INSTITUTE OF INFORMATION TECHNOLOGY

TIRUCHIRAPPALLI
(An Institute of National Importance under MHRD, Govt. of India)
NIT CAMPUS, TIRUCHIRAPPALLI -15
Mail id: dean-iiits@nitt.edu Contact No.: 0431-2500539,2500439

Application Form for Teaching Post

For office use APPL. No:

WALK IN INTERVIEW
[Purely Temporary position on Contract basis]
Please read the information carefully on website prior to filling up this application form. You may use
separate sheet/s wherever required. Documentary evidence(s) is/are to be attached for the data provided
in this application failing which due weightage will not be given during scrutiny.

Advertisement No. & Date: ……………………………………………………

Post Applied for: ……………………………………………………………… Please affix recent passport

size photograph
Department: ……………………………………………………………………

Specialization: ………………………………………………………………...

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1. (i) Full Name (in BLOCK letters): ………………………………………………………...…...……............

(ii) Father’s/Husband’s Name :.………………………………………………………………............

(iii) Mather’s Name :.………………………………………………………………............
(iv) Whether belonging to GEN/ SC/ST/OBC/PH: ……………………………………………………..........
(Attach Certificate)

2. Date of Birth: …………………… 3. (a) Nationality: ..................................... (b) Gender: Male / Female

(c) State/UT to which you belong: ………………………………………………………………………........

(d)Marital Status: Married / Unmarried / Divorced ………………………………………………….............

4. Postal Address for correspondence. 5. Permanent Address (with Phone no. & Mobile):

..…………………………………………….. ....………………………………………………......

……………………………………………..... …...………………………………...........................

……………………………………………..... …...………………………………............................

..…………………...Pin Code: ………........... ……………………....Pin Code: ………..................

Phone No.: Office: ………………………… ... Phone No.: Office: …………………………............

Res.: ……..………………………………….... Res.: ……..………………………………….............

(With STD Code)
Mobile No.: ………...……….... ….... E-mail ID: ………………………………..…………

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6. (a) Educational Qualifications (Start with Highest Qualification):

Sl. Examination Name of the Month Subject/ % of Marks/ Division / Class

No. Passed University/Board & Year Specialization Grade (CGPA)
of
Passing

(b) Have you qualified GATE? (if yes provide the details such as score/percentile, Rank and validity)

Registration Registration All India Total number Marks out of Validity Gate
Number paper rank of candidates 100 period score
appeared

7. Prizes, Awards, Rank received etc. (if any, attach certificate): ……………………...……….................

……………………………………………………………………………….........................................................

8. Have you participated in NCC/Sports? ………………………………….........................................................

9. (a) Post held at present:

Post held Date of Appointment Nature of the Post Name & Address of
(Temporary/Probation/ Employer *
Permanent)

* Copy of appointment order to be attached

(b) Present Pay Scale: ………………… AGP/GP …………………… Any other Pay:..…………………........

Basic Pay: ………………........ Dearness Allowance: ………………..... Gross Pay: …………………………..

Emolument: …..………………

(c) Type of organization (Government/Semi-Government/Govt. Aided/Autonomous Body/ Private etc.)

………………………………………… ...……………………………………………………………….............

………………………………………… ...……………………………………………………………….............
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10. Professional Experience (In the reverse chronological order):

Sl. Name of the Post held Period of Employment Pay Scale and Total Reasons for
No Employer Basic Pay Emolument Leaving
. drawn
From To

11. (a) Total Experience:

(i) Teaching U.G.:…………….Year(s) ..................... Month(s)

P.G.:…………….Year(s) ......................Month(s)

(ii) Research (excluding Ph. D duration) : …………….Year(s) ...................... Month(s)

(iii) Industrial : …………….Year(s) ..................... Month(s)

(b) Any break in Service: Yes/No

If yes, state the period of break & reasons: …………….Year(s) .................... Month(s)

…………………………………………………………………………………………………….
12. (a) Thesis supervised: Ph. D. (If any)

Sl. Title of the Thesis Supervised Completed (year) In progress Principal or

No. (With Status) Co- Supervisor

(b) Thesis supervised: M. Tech. / M.S. / M. Phil.

Sl. Title of the Thesis Supervised Completed (year) In progress Principal or

No. (With Status) Co- Supervisor

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 (c) List of Publications (National/International Journals): Attach the Reprint of SCI/SCIE/
SCOUPUS journals only

Sl. Journal Name Impact Vol. Year/Page Authors Title of the National/ SCI/SCIE/
Nos. paper Intenatio SCOUPUS
No. with ISSN Factor No. nal

(d) List of Book/Book chapters (Attach the photo copy of the first page of the book highlighting
ISBN number)
Sl. Name of the Book/Book chapters Authors Book International Publisher
/Book chapters /National
No.

(e) Research Activities (with documentary evidence):

Sl. Sponsored/ Consultancy Duration (date) Sponsoring Funds Present Status

No. Projects Authority Sanctioned(Rs.) (Completed/
In progress)
From To

(f) Conference/ Symposium (International level) attended (Applicable if full text of paper is published in
the proceedings):

Sl. Name of the International Month/ Year / Vol. No./ Title of the paper
No. Conference/Symposium with Venue Page No. Issue No.

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(g) Conference/ Symposium / Training Programs (National level) attended (Applicable if full text of paper
is published in the proceedings):

Sl. Name of the National Month/ Year Vol. No. Title of the paper
No. Conference/Symposium / Training / Page No. /Issue No.
Programmes with Venue

(h) Conference / Seminar / Workshops organized as Coordinator/Chairperson:

Sl. Title of the Conference / Month/Year Venue Sponsoring Authority

No. Seminar / Workshop organized

(i) Summer / Winter Schools/ Training Programmes organized / attended:

Sl. Title Venue Duration Sponsoring Authority

No.

(j) Experiments or Computational design projects added to Teaching labs:

Sl. Name of the Lab. & Institute Title of the Experiment / Design Year in which added
No. Project

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(k) Any E-learning material prepared for Teaching / Laboratory:……………………………………..............

…………………………………………………………………………………………………………….............

13. Administrative experience: (e.g. Dean /Hostel Warden/HOD etc.)

Sl. Name of the Duration Nature of responsibility

No. Assignment

13. Membership of Technical Societies :…………………………………………………………………..........

(Including Membership no.)
………………………………………………………………….……………………………………...........

14. Extra Curricular Activities: ……………………………………………………………………………..........

………………………………………………………………….……………………………………...........

15. Please give details of three referees (Not related to the candidate), At least one should be the
current / previous employer:

(i) Name: ……………………………….............. (i) Name: ………………………………..................

Designation: …………………………............. Designation: ………………………………........

Full Address:……………………………........ Full Address: ………………………………......

……………………………………................... …………………………………….....................

Contact No. …………………………….......... Contact No. ……………………………............

E-mail:………………………………….......... E-mail:………………………………………......

16. Any other relevant information :………………………………………………………………….............

…………………………………………………………………………………………………………................
………………………………………………………………………………………………………................

DECLARATION

I declare that the statements made in this application are true to the best of my knowledge and
belief. I understand that misleading or wrong information supplied may lead to summarily rejection
of application /appointment (if found subsequently).
Date: ------------------------------------

Place: (Signature of Applicant)

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 DATA SHEET

Department applied
for:
Full Name
Date of Birth Age (as on 1-1-2019) Gender
Category SC/ST/OBC/PwD/UR
Total Teaching Number of
/Research seminar/workshop/Conference
experience organised Attach passport
size photo here
Number of M.Tech. Total industrial experience
thesis supervised

Number of journal SCI: SCIE: SCOUPUS:

publications
(SCI/SCIE/SCOUPUS)

National publications International Publications

Number of Books published
Number of Book chapter
published

Conference presentations
Year of Institute and Discipline Class/Divisio Number of courses Merit
passing University n attempted more
than once
UG

PG

Date of Date of viva Institute and Title of the thesis Merit

Thesis voce University
submitted
Ph. D

Registration number Registration All India Marks Validity Gate

paper rank out of period score
100
Gate
qualification
Signature of the Applicant: