NATIONAL ENVIRONMENTAL ENGINEERING RESEARCH INSTITUTE

(An ISO 9001 – 2000 certified organization)

(Council of Scientific & Industrial Research)
NEHRU MARG, NAGPUR – 440020
Tel.No.0712-2249885-88, 2249970-72 FAX No.0712-2249900 Website: www.neeri.res.in

APPLICATION FORM
(Use only A4 size thick paper for printing the form and for the enclosures. Please ( √) in the appropriate boxes)

Application Fee

Advertisement No. ………………. Amount Rs. ….……

DD No. …………………… Affix a duly signed

Name of the Post applied for & Date …………………… recent passport size
photograph
…………………………………… Name of the Issuing Bank
…………………………………………….
……………………………………………
Post Code No. …………………….
(For office use only)
Removed DD for handing over to Accounts
Section for credit into NEERI A/c. Also please attach one
additional photo signed
Sl.No……… Page No.……. Date …….... of by the candidate
the Application Fee Register

Dealing Assistant / Section Officer (P&V)

1. Name of the Applicant : ………………………………………………………………………..…..

(in BLOCK LETTERS)

2. Sex : Male Female

3. ADDRESS :

(a) POSTAL ADDRESS : ……………………………………………………………………………

……………………………………………………………………………
....................................................................................................................
District ………………………… State …………………………………
PIN CODE

Telephone No. ……………………………………… E-mail Address ………………..…………………….

FAX No. ……….…………………………

Nearest Railway Station to the normal place of residence: ……………………………………………….

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(b) PERMANENT ADDRES : …………………………………………………………………………
………………………………………………………………………….
………………………………………………………………………….
District ………………………… State ………………………………
PIN CODE

Telephone No. ………………………………………

---------------------------------------------------------Note----------------------------------------------------------------------
All the communications will be sent to the postal address. Any change of address as given in column No.3 above should
at once be communicated to the Administrative Officer, NEERI. Candidates must arrange for the re-direction of
communication to their changed address. if necessary, in their own interest. The Institute will make every effort to take
account of change in the candidate’s address but cannot accept any responsibility in this matter.
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4. Date of Birth (as per SSC/ : Day Month Year

SSLC/Matric Certificate)
& (In words) ………………………………………………………………….
Place of Birth : Place : …………………………………………………………………..

5. Age as on closing date for: Years Months Days

receipt of application

6. Are you a citizen of India : Yes No

by birth and/or by domicile?

7. Name of the State/Union Territory to which you belong? : ……………………………………..

8. Father’s full Name * : ……………………………………………………………………..

Address : ……………………………………………………………………
……………………………………………………………………
……………………………………………………………………
Occupation : ……………………………………………………………………
(* In case of demise, state his last address and occupation before death)

9. State your Religion : …………………………………………………………………….

10. Caste / Community :

(Enclose attested copy of latest valid
Certificate from the competent authority) SC ST OBC GEN PWD

11. Passport Details : ………………………………………………………………………………

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12. Are you related to any employee of NEERI/CSIR and its National Laboratories/Institutes? If so, please
state:
Name of the relation Designation Name of the Laboratory/Institute/ Relationship
Unit/Centre where working

13. Particulars of all examinations passed and degrees and technical qualifications obtained at the university or
other places of higher technical education or institutions (chronologically commencing with the
matriculation or equivalent examination):
Examination Name of the Year of Class or % of Subjects taken / Specialization
passed/ Diploma Board/ University/ Passing Division marks /
Degree obtained Institution GPA

14. Professional Training, if any: ………………………………………………………………………………..

……………………………………………………………………………….

15. Details of post graduate work and published papers: Give titles of papers here and attach reprints.
(If the space below is insufficient give full particulars on a sheet of separate paper and attach it with this
application indicating here the reference to the sheet attached)
……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

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16. Experience (Starting from the present employment – experience certificate to be attached – Furnish a
resume of work done with list of publications/projects, if any, separately)
Name & Address of Post held/ Nature Period Permanent/ Salary & Grade
the employer of employment Temporary
From To

17. Have you been outside India? If so, give the following particulars:

Country visited Date of visit Duration of visit Purpose of visit

18. What languages (including Indian Languages) can you read, write or speak? Give particulars and state
examinations passed in each, if any:

Read only Speak only Read & Speak Read, Write & Speak Examination passed

19. Any other relevant information: ……………………………………………………………………………

20. Are you under any bond/contractual obligation to serve Central/State Government/Public Sector
Undertaking/Autonomous or any other Body? If yes, give details:

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
……

21. Notice required to be given by you to your employer/ : Maximum ………………………..

Joining time required for you from the date of receipt
of offer of appointment, if selected. Minimum ………………………..

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22. References:
The referees should be residents of 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 a
referee or produce a testimonial from him in regard to the candidate’s fitness for the post for which he is
an applicant:

Sl. Name of the referee Occupation/Position Address

No.
1.

2.

3.

(Attested copies of testimonials only from three eminent persons to be submitted)

23. Are you a Member of any Scientific Society/Professional Body? If so, give details:

24. List of documents attached:

1) 7)

2) 8)

3) 9)

4) 10)

5) 11)

6) 12)

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 DECLARATION

I hereby declare that all the statements made by me in this application are true and complete to the best of my
knowledge and belief and nothing has been concealed/distorted. I am aware that if at any time I am found to
have concealed/distorted any material information, my appointment is liable to be summarily terminated
without notice.

I have applied for the post through proper channel. I have informed my employer in writing that I am applying
for the above post (in case of candidates who are already employed) and shall produce the no objection
certificate to attend the interview/test, if called for, and relieving order at the time of joining NEERI(CSIR), if
selected.

Place :

Date : --------------------------------------------
Signature of candidate

(Please remember to send one additional photograph (preferably coloured) along with the application, either
well stapled or put in a separate polythene cover attached to the application. The candidate should put his full
signature on this additional photograph (front portion). Please sign at the bottom of all the pages of application
in addition to signature at the end of the application in the space provided for).

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 SYNOPSIS
( Advt No.1/2010)
1. Post Applied for : Post Code No.:
2. Name of Candidate :
3. Category
SC ST OBC GEN PWD
4. Date of Birth : Day Month Year

5. Age as on closing date: Years Months Days

6. Qualifications: (starting with Matriculation)

Sl Examination / Board / Year of Class / % of marks Subject specialization
No. Diploma / University passing Division / GPA
Degree
1.
2.
3.
4.
5.
6.

7. Main area of specialization (Not more than two):

1. 2.

8. Experience:
Name & Address of Post Held Period Permanent / Salary & Grade
Employer From To Temporary

9. Publications (Nos. only) :

Authorship National International
Single
Multiple

10. Prizes/Honors/Awards Distinctions (only important awards etc.):

………………………………………………………………………………………………………………
……………………………………………………………………………………………………………

Date : Signature of Candidate

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