NATIONAL INSTITUTE OF ROCK MECHANICS
(an Autonomous Research Institute under the Ministry of Mines, Government of India)
Champion Reefs, Kolar Gold Fields- 563 117, Karnataka, INDIA
APPLICATION FORM
( Neatly filled in application forms should reach the DIRECTOR, NIRM, KGF latest by the due date as indicated in
the advertisement. Applications without supporting fee or with illegible or incomplete entries will be rejected.
Read carefully the instructions in italics for each point before filling in this form).
Advertisement No. : ..
Due date
________________________________________________________________________________________________________________
APPLICATION FOR THE POST OF ________________
___________________________________________________________________________
1. Name (in BLOCK LETTERS)
(Female applicants to prefix Ms.)
Affix here a
passport
size
photograph and
sign across with
your name on
the top.
2. a. Fathers Name
:
b. Occupation (Past, if retired) :
3. (a) Address for communication :
Any change in address after submission
of application form should be notified
to this office immediately.
(b) Permanent address
(c) Contact phone No :
(prefix STD code)
(d) e-mail id
:
4. a. Nationality
b. Passport No.
:
:
5. If you are a persion of Indian origin, please state (strike off the option not applicable)
(a) Whether a citizen of India by birth ?
If yes, then state to which you belong
:
:
YES / NO
(b) Whether a person migrated from Pakistan/ Bangladesh
YES / NO
(c) Whether a subject of Nepal or resident of Sikkim?
YES / NO
6. Details of the application fee paid (Mention DD No. and Bank details; No fee for SC/ST):
.
7. (a) Date (& Place) of birth :
(b) Marital Status :
Married/ Single
(Enclose proof in support of date of birth)
(Strike off the option not applicable)
8. Nature of present work/ job (Write the correct option) .: ..
GOVERNMENT SERVANT/ PRIVATE EMPLOYEE/ CONTRACT WORKER/ OTHER (SPECIFY)
9. Category (General/ SC/ ST/ OBC/ PH / Other(specify))
:
(Please attach appropriate certificate, if you belong to reserved category)
10. (a) Have you ever been suspended or dismissed from past service
: YES/ NO
(b) Have you ever been arrested/ prosecuted (while in service or otherwise) : YES/ NO
11. (a) Religion to which you belong
(b) Have you ever changed your religion
: YES/ NO
12. Educational & Professional qualifications - (Start with SSLC/ SSC)
Exam
Passed
Board/
University
Duration
of study
Year of
passing
13. No. of publications :
(a) International (Journals) : .....................
(b) National (Journal)
: .....................
(c) Other publications
: .....................
Major
Subject(s)
CGPA/ %
of marks
Class
International (Symposium) : .....................
National (Symposium)
: .....................
(list details of last five significant publications and enclose copies) :
i.
ii.
iii.
iv.
v.
14. Experience relevant to the area of specialisation as per advertisement (mention in detail) :
a.
b.
c.
d.
15. Have you been outside India? If YES, please provide details below :
Country visited
Period of visit
Purpose of visit
16. Employment details (in reverse chronological order)
(Enclose certificate of experience in respect of minimum desirable qualification)
Employer
Date of
Joining
Date of
Leaving
Designation
Nature of
Job done
Gross
monthly pay
17. Have you applied for any other post(s) at NIRM earlier ? YES/ NO
(If applied during last five years, please mention details)
Advt. No.
Date of
Application
Post applied for
Whether called
for Interview
Date of Interview
18. Name and address of two Referees for verifying your credentials :
1.
..
..
2
..
..
19. a. Are you a Government Servant ?
: YES / NO
b. If yes, then nature of appointment ? : TEMPORARY/ PERMANENT/ CONTRACT
20. a. Are you willing to accept the minimum initial pay offered?
: YES / NO
b. If NO, then the lowest initial monthly basic pay expected
: RsPM
c. Minimum joining time required, if selected for the post
:.. days
(Any request for extension of joining time will not normally be considered)
I hereby declare that the information furnished in this form is true to the best of my
knowledge and belief. If, at any stage, if they are found misleading or untrue, my candidature
or appointment to the post may be rejected/ cancelled.
Place :
NOTE : Application form without
signature and date will be rejected
Signature of Applicant
Date : --------------------
ENDORSEMENT FROM THE HEAD OF THE INSTITUTION
___________________________________________________________________________
(Candidates already employed should route their application through proper channel with
the following endorsement either on this application form or separately. While they may
submit an advance copy, the duly forwarded copy by the present employer should reach
the destination within 15 days of closing date of receipt of Direct application forms)
__________________________________________________________________________________
This Organization/ Institution has no objection to allow . to
apply for the post of against Advertisement No. ... of the
National Institute of Rock Mechanics, KGF.
Signature with date
Office seal
Name & Designation :
with seal/ stamp
Check-list of enclosures* (Attested photocopy only, original should not be submitted) :
1. Certificate in support of date of birth
: YES/ NO
2. Certificate of the qualifying examination
: YES/ NO
3. Certificate for SC/ ST/ OBC/ PH / Other reserved category : YES/ NO
4. Essential experience certificate1
: YES/ NO
5. Passport size signed photo affixed
: YES/ NO
6. DD towards application fee
: YES/ NO/ Exempted
5. Endorsement/ forwarding letter/ NOC **
: YES/ NO/ N A
7. Other enclosures in support of your application
: Please mention below
a)
b)
c)
d)
e)
..
* Strike off the option not applicable. Applications without essential enclosures (1-6) will be rejected.
** Applicable only for persons employed in state/ central government service.
1. Application received without these two relevant documents will not be processed.
