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APPLICATION FORM

Hand-written applications and/or any addition/deletion in the format of the Application

Form will lead to rejection of the candidature.
POST APPLIED
Chief Manager
(Technology)
Deputy Manager
(Business Development)
Deputy Manager
(Technology)
Deputy Manager
(Finance & Accounts)
Assistant Manager
(Business Development)
Assistant Manager
(Technology)

REQUIRED FIELD AS PER EXPERIENCE

Please (tick ) only one option. In case applying for more than one
field, submit a fresh Application Form)

Testing Mechanical

Non Destructive Training

Testing Chemical
Computer Training

Computer Aided
Engineering
PLC Robotics

Tool Room Training

Electrical

Quality Control Training

Incubation

Refrigeration & AC
Training
Design

Computer Aided Design

Assistant Manager
(Finance & Accounts)
Please copy the tick mark symbol and paste it wherever needed in the Application Form.
NOTE: Fields Marked * are Mandatory. In Case Mandatory fields are not filled, the Application
Form will be rejected.

A) PERSONAL DETAILS

1.

Name Of Applicant*
(in BLOCK letters)
Fathers/Mothers Name*

AMRITANSHU MISHRA

13-12-1984

4.

Date Of Birth*
(dd/mm/yyyy)
Aadhaar No.

5.

Category*

General

2.
3.

Dr. S.D. Mishra

SC

ST

OBC

Yes

No

7.

Whether belongs to
Person with Disability
Category *
Gender*

8.

Marital Status

Married

6.

9.

Whether belongs to
Minority Community*
10. E-mail*
11. Mobile*
12. Complete Current
Residential Address

13. Permanent Residential

Address Complete

Male

Female

Yes
eemishra@gmail.com
9839883322
House No.
Street Name
City
District*
State*
Pin code*
House No.

Transgender
Single
No

B 33/10-K-18-A-11 Mangalam Tower

Rohit Nagar, Nariya, Sunderpur, Lanka
Varanasi
Varanasi
Uttar Pradesh
221004
C/o Dr. Pratima Pandey, Pandey
Nursing Home, Bus Stand

Street Name
City
District*
State*
Pin Code*

Gopiganj
Sant Ravidas Nagar, Bhadohi
Uttar Pradesh
221303

B) EDUCATIONAL QUALIFICATION* (Xth Class onwards)

#

Name of
Examination / Degree
passed
(No abbreviation to be
used)

Full
Name
of Duration Date of Regular/ %age
Board/University/Institut (Only in passing Distance/
e (No abbreviation to be years)
Part-time
used)

Indian Certificate Of Council for the Indian

Secondry Education

(Class 10th)
All
India
School

School

Certificate

Examinations
Senior Central
Board

Of Allahabad

Technology

, Institute

Of

Biotechnology

25-05-

Regular 63.6

2002

Agriculture

Regular 73

2000

Certificate Secondary Education

Examination
Bachelor

07-05-

Deemed

07-09-

Regular 68.9

2007

University

4
C) Post-Graduation Diploma / Masters Degree*{Including CA / ICWA (CMA) / CA (Inter) /
ICWA(CMA)(Inter), as the case may be}
#

Full Name of Specialization

Masters
Degree / PG
Diploma
(No
abbreviation to
be used)
Post Graduate
Marketing

Full Name of Duration Date of Regular/

University / (Only in passing Distance/
Institute (No years)
Part-time
abbreviation
to be used)

%age

Jaipuriya

56.62

Diploma In

Institute Of

Management

Management,

Master of

Marketing

Lucknow
Shobhit

Business

Management

University

12-05-

Regular

2011

24-09-

Distance 61.78

2014

Learning

Administration
3
4

D) EXPERIENCE* (Starting from the present employer) {In case of CA / ICWA(CMA) / CA(Inter) /
ICWA(CMA)(Inter), as the case may be, Article-ship / Practical Training may be shown as experience}
#

Full Name of
Employer (No
Abbreviation to be
used)
Centum Learning

Designation

Duration
DD/MM/YYYY
From
To

Admin

25-11-

Centre Varanasi

Manager

2013

Present

Job profile
(Maximum 30
words)
Looking after Admin
duties, admissions,
Marketing,

Gross
Salary
(Per
month)
20,000

Promotion, Sales,
purchasing,
maintenance, hiring
2

Reliance Retail

Assistant

12-02-

15-11-

and training of staff.

Cash Team

Limited

Manager -

2013

2013

management and

Operations

20,000

Non Food section

Display, Sales,
Promotion, Team
management,

Future Retail Limited

Managemen

04-07-

05-04-

Training
Looking after

t Trainee

2011

2012

fashion section.

28,210

Managing Floor,
Marketing activities,
Team Management,
4

Pandey Nursing

Admin

01-07-

01-07-

Training, B2b Sales

Looking after the

Home, Gopiganj

Manager

2007

2009

operations of the

16000

hospital, marketing
and promotions of
the hospital in
nearby areas.
5

E) ADDITIONAL QUALIFICATION / TRAINING ATTENDED (of more than 3 months duration), if any
#
1
2
3
4
5

Full Name of Qualification / Training

(No abbreviation to be used)

Duration
(In months /
years)

Brief Description
(Maximum 30 words)

F) WHETHER WORKING AS PERMANENT / CONTRACT EMPLOYEE IN GOVT. / SEMI GOVT. / PSUS /

BANKS / LOCAL BODIES ETC.*?

Yes

Permanent

If Yes, Please mention the particulars of your HR Head / Personnel

Deptt.
Name ____________________________________________________

Contract
No

Address __________________________________________________
__________________________________________________________
Phone No. _________________________

G) HAVE YOU EVER APPEARED IN INTERVIEW FOR ANY POST IN NSIC DURING LAST 3 YEARS*?
If Yes, Please mention the name of the Post and Year of Interview

Yes
No

Post _________________________________________________________

Year _______________________________________________________

H) PAYMENT DETAILS*
Demand Draft
Number
Date

Name of the Issuing Bank

Address of the Issuing

Branch

Amount
(in Rs.)

Self- Declaration of applicant*

(a) I declare that I have carefully read all the Guidelines mentioned along with the
detailed advertisement hosted on NSIC website.
(b) I have verified the above details, and the details are in order to the best of my

knowledge & belief.

(c) I understand that merely filling this Application Form will not be treated a complete
YES
application. Therefore, I further declare that I will send this Application Form with selfattested copies of all documents as per pt. 4 & 5 of How to Apply (pt. IV of Guidelines)
to DGM (HR), NSIC Ltd. so that the same is received on or before 11.07.2016 upto 6.00
p.m.
Place of Submission*: _______________________
Date of Submission*: ________________________

_______________________
Signature of the Applicant*