: eam) UNVERSITY GRANTS COMMISSION 2| ACADEMIC STAFF COLLEGE « swear a UNIVERSITY OF MADRAS ae Chennai - 600 005. Applicaton for OxeationPropassme/ to ep dimemmtcmarts | Retesher Cour / Short Tem Couse Spel Coune ae ee iw ot = Vecssaied = Come te Bae mae ee ao 1. Nate ofthe acer Ga Bleck Late) 2, DateofBith& Age 3. Gender 2 Male Bemle 4 ‘Educational Qualification 5. Commasity sr/sc/wpcrac/oc 6 Designation Asst Profesor soit Profesor 1. Deparment 8. Adds fr Conespondnce Cates Unie 2 FA see BM eee 9. Typeofthe Educational Insition Neprgemers veemcuo (Ser Fimaced / 10, Name of tie Affitating Univesity 11, Datoof Appoint : 12, Nature opponent + Regular/Probat / Temporary eagles ees UG: Yours, PG: Years; Total Years 14, Area of interest ofthe Applicant 15, Details of Courses Attended Course Dates Place oP RC Short Term Course Declaration : The particulars which are given above are tru to the best of my knowledge and belief Place Signature ofthe Applicant Date Appl Recommendation ofthe Forwarding Authority hereby certify that: 1. The information fumishod above ap comect 2. The College i within the puview See. 2(F) o Se 12B ofthe UGC Act. 3. The College i aliated othe University frst 5 year, request you to coaside this aplicatinn forthe benefit ofthe incumbent and assur ou tht the teacher wil ‘erlived on te to participate in tm care, fsleted ‘Signatre of the Hea ofthe Department Signature ofthe forwarding Authority Date Seal For Ottce Use only Admited Not Admited Direcor UGC-ASC-UOM