CENTRAL INSTITUTE OF PETROCHEMICALS ENGINEERING & TECHNOLOGY (CIPET)
(An Autonomous Body under Ministry of Chemicals & Fertilizers, Govt of India)
NH – 31, Changsari, Guwahati, Kamrup Dist., Assam – 781101
E-mail: guwahati@[Link]
UTE OF PLASTICS ENG & TECHNOLOGY (CI
APPLICATION FORM FOR CONTRACTUAL ENGAGEMENT FOR LIMITED OR
FIXED PERIOD IN CIPET
Note: i) Please read the attached information regarding last date of submission of duly completed
application form, eligibility criteria, educational qualifications & experience and general terms and
conditions before filling the application form.
ii) Please tick ( ) wherever applicable.
1. Contractual Position Applied For: Paste recent
passport size
photograph
2. Centre applied for :
(Applicable if advertisement is in r/o contractual position at more than one CIPET Centres)
3. Full Name
(in BLOCK letters)
4. Date of Birth Blood Group
5. Community
(SC/ST/OBC/GEN)
(enclose self-attested copy of certifcate)
6. Whether Economically Weaker Sections (EWSs) Yes
No (enclose self-attested copy of certifcate)
7. Whether Physically Challenged Yes No
If yes, state % of
disability (certificate to
be enclosed)
8. Whether Ex-Servicemen Yes No
9. Gender Male Female Others
10. Marital status Married Single Others
11. Nationality Religion
12. Mother Tongue
13. (a) Name and address of
parents
(b) Name of spouse (if applicable)
(c) if spouse is employed,
(provide employer name & place)
14. Present postal address
for correspondence
Tel : Mob :
E-mail:
15. Place of Upbringing /
Hometown:
16. Permanent address
17. Present employment
Employer’s Website:
18. Were you at any time declared medically unfit; asked to submit your resignation;
discharged or dismissed from Govt./Semi-Govt./Autonomous Body or Private Service?
If yes, provide details in a separate sheet.
19. Have you ever faced any vigilance enquiry or enquiry by an anti-corruption bureau/
Central Bureau of Investigation or any other Investigative Organization
Yes No
If yes, please indicate in brief, the details of the vigilance enquiry and outcome thereof in a
separate sheet.
20. Academic Qualifications:
(Please attach self attested photocopies of UG/PG Certificates /
marksheets) provide particulars in a chronological order starting
from SSLC (Xth Std).
Duration
Pass
Mode of % of of
Name of Divisio
S. Subject/ study Full Marks course Year
Course / Degree n (I or
No Specializati Time / Part / (whethe of
/ University II or III)
on time CGPS r 1 yr. or passin
/ Board Class
/ 2 g
Correspondenc yrs. or 3
e yrs.
course
21. Details of your Ph.D Thesis (If
applicable) (enclose abstract of
Thesis)
Sl. No. Degree Title of Thesis University
01. Ph.D.
22. Professional Qualification(s) (e.g. Professional Training, Courses, Workshops etc.
attended, in case applicable for the position applied for)
(enclose as a separate sheet)
23. Employment details* : (Details in chronological order, starting with present employment
upto the first employment)
Period of
Position Pay Place /
Name & Address of Employme Nature
Sl. held / Scale & state of
Organization / nt of
No. Designation Gross employme
Employer (Month/Yea duties
Salary nt
r)
From To
(*enclose extra sheet, if required)
24. Please furnish details regarding Nature of duties, Job Description/Resposibilities,
Experience and Major achievements, if any, in your past/present employment
(Use a separate sheet, if required)
25. Reference:
Responsible persons not related to the applicant but closely acquainted with the applicant
Name and Designation Address
1.
Mob:
Email
:
2.
Mob:
Email
26. Notice period required for completing relieving formalities with present Employer on
selection:
27. Details of relatives working at CIPET, if any :
28. Any other information you may like to furnish to CIPET:
29. Provide details of your Social / Political / Religious Affiliations, if any:
30. Copies of documents enclosed:
(i) .
(ii) .
(iii) .
(iv) .
(v) .
(vi) .
(vii) .
(viii) .
(ix) .
(x) .
DECLARATION
I declare that the entries made in the columns of this “Application Form for
Contractual Engagement for limited or fixed period in CIPET” are correct
and true to the best of my knowledge & belief and nothing has been either
concealed or misrepresented by me. In case of any concealment or
misrepresentation, noticed during the engagement / at a later date, I
understand that contractual engagement, if gained, is liable to be
terminated forthwith without notice to me.
Place: Signature
Date:
N.B.: 1) Use separate sheets wherever necessary while filling the application
form.
2) All entries in this application form shall be neatly typed /written.s &
Fertilize India