14-05-2012 to 09-06-2012 - Jawaharlal Nehru Technological ...

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APPLICATION FORM(28 th Orientation Course)1. Name: …………………………………..............2. Date of Birth & Age: ……………………………………….......3. Gender (M / F): ………………………………...................4. Qualifications : …………………………………………...5. Category : SC / ST / OBC / any other6. Teaching Experience : …………………………………………...7. a) Designation : …………………………………………...b) Department: ............……………………………………c) Pay Scale & Present Basic : .............………………………..8. a) Institution : …………………………………………..b) Affiliating University :.............……………………………….9. Whether your Institution/University is approved by UGC : YES / NO10. College Address :………………………………………….........................................................…………………………………………..............................................11. Residential Address :.............……………………………………...............................................12. Phones Nos:......…………………………………………...........................................(O) .........................................MOBILE:................................(R)...………..………………………Fax:…...……………...................E - mail ID: ...........………………………………………………......13. D.D.No., Date and Bank details: ................…………………14. Nearest Railway Station : ...……………………………………15. Previous Participations in UGC: ............…………………………Orientation & Refresher Courses........................................S. No Course Title Date Place
DECLARATIONThe Information furnished above is true to the best of my knowledge. I agree to abide bythe rules and regulations governing the Course. If selected, I shall attend the coursedefinitely for the entire duration. I also undertake the responsibility to inform theDirector, Academic Staff College sufficiently in advance (at least one week), in case I amunable to attend the Course.Place :Date :Signature of the ApplicantName:SPONSORSHIP CERTIFICATECertified that ____________________________________ is a regular employee of ourinstitution since _____________, and is hereby sponsored for the 28 th OrientationCourse, at UGC - Academic Staff College, JNTU Hyderabad during the period14-05-2012 to 09-06-2012. From the year _________, our College is affiliated to_____________________________________ University, which is approved by theUGC. He /She will be permitted to attend the course without fail, if selected.Signature of the Registrar /Principal / Director with SealPlace :Date :Note to Sponsoring Authority :1. It is mandatory that the sponsored teachers, if selected, should be deputed for theCourse.2. Hardcopy application along with Rs. 500/- D.D. is compulsory for confirmingthe participation.
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14-05-2012 to 09-06-2012 - Jawaharlal Nehru Technological ...

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