Indian Institute of Technology Hyderabad

APPLICATION FORM FOR APPOINTMENT BY SELECTION

FOR POST No.21, 22, or 23 only.
Advertisement No.IITH/2017/Rec/NF/6.
[Please read General Instructions to Candidates
before filling up the application.]

For office use only

Affix a recent
Application No. passport size
photograph duly
attested by the
candidate

4CmX5 Cm

[Photo to be attested by the Candidate]

Post No.

Name of the post

[As stated in the advertisement]
Area

[Please see Table 1, Table 2, or Table 3 in the

Advertisement as may be applicable to the
post applied for]

01. Application fee - Details [If exempt write Exempt ]

Challan journal number:
(will be found in challan)

Date of payment:

Amount in Rs.

Note: IITH copy of challan, in

original, should be enclosed
with hard copy of the
application
02. Name in full (in capital letters)
th
[As stated in 10 standard
marks sheet]

03. Fathers/Husbands name

04. Date of birth

(Date/Month/Year)
th
[As stated in 10 standard
marks sheet]

05. Postal address for

communication. [Candidates
may, at their option, state e-
mail id, mobile/land line
number.]

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06. Permanent address

[Candidates may, at their

option, state e-mail id,
mobile/land line number.]

[If permanent address is the

same as postal address for
communication, write Same
as postal address.]

07. Religion

In respect of Columns 08 to 12 strike out the incorrect answer as shown alongside - Yes / No for
yes and Yes / No for no. Any other form of answer like underlining, circling, tick mark, etc., will
NOT be accepted.

08. Nationality Indian - Yes / No

Other National Yes / No

09. Gender Male Yes / No

Female Yes / No

10. Category SC Yes / No ST Yes / No

OBC Yes / No UR Yes / No

SC/ST/OBC candidates should attach an attested copy of

certificate issued by the competent authority in the format
prescribed by the Government. The Institute follows the
Central List in case of OBC. OBC certificate format has
been prescribed by Government of India.

Production of attested copy of certificate is compulsory for

SC/ST/OBC candidates.

Please note that the benefit of reservation accrues only

against posts reserved and subject to the candidate
furnishing the requisite certificate.

11. Do you belong to - Ex-servicemen Yes / No

Physically Handicapped Yes / No

If YES, please attach an attested copy of certificate issued

by the competent authority on the format prescribed by the
Government of India.
12. Have you ever been convicted Yes / No
by a Court of Law or is there
any criminal/
disciplinary/vigilance case
If YES please give details in separate sheets.
pending against you?

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 13. Educational/Professional and Technical Qualifications (Attach attested copies of
Certificates and Mark Sheets):
Duration Division/
Examination Name of the of Degree/ Year of % of Class
Specialization
Passed Board/University Diploma/ Passing Marks
Training

14. Details of knowledge, employment and training in reverse chronological order (Attach attested
copies of Certificates): (Attach separate sheet, if necessary):
Period of employment Scale of Pay
Department/ Regular/ Temporary/
Post held
Institute/Office Permanent/ Contract
From To

15. Pay in the Pay Band and Grade Pay / Pay in the
pay scale, and total emoluments or consolidated
emoluments drawn in the post currently held:
16. Referees: [Optional for posts below Grade Pay Rs.5400]
A. Name
Designation

Postal address

Phone number
Landline: Mobile:
E-mail id

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B. Name
Designation

Postal address

Phone number Landline: Mobile:

E-mail id:
C. Name
Designation

Postal address

Phone number: Landline: Mobile:

E-mail id:

17. Are you a member of any

professional body? If yes,
give details:

18. Details of enclosures. If space provided is not sufficient, attach separate sheet in the format
given below): IMPORTANT: ALL THE ENCLOSURES SHOULD BE ATTESTED and serially page
numbered.

Sl. Description Page No.

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 DECLARATION

I hereby declare that I have carefully read and understood the General Instructions to Candidates
and that all the entries in this form are true to the best of my knowledge and belief. I also declare
that I have not concealed any material information that may debar my candidature for the post
applied for. In the event of suppression or distortion of any fact in my application form,
I understand that I will be denied any employment in the Institute and if already employed on any
of the posts in the Institute; my services will be terminated forthwith.

Place:

Date: Signature of the Applicant

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