^oatea, ffi.2018

Copy To:

I . Rcgistrar, ICKV. Raipur (C.C. ₎

1. P.A. to Hon'ble V.C., IGKV, Raipur (C.G.)
   
   
2. Dean, College of Agriculture/ Agricultural Engineering, Raipur (C.C.)
   
   
3. Prof. & Head ofdepanment Agricultural Engineering/Agricultural Extension/ Agricultural Economics/ Agricultural _{n -Tstatistics} & Social Science/Forestr)/Agri-Business & Rural Management, CoA. Raipur (C.C.) _.\T
   
   

95. ln-charge. IGKV MlS, Raipur wirh requesr ro upload on universil.; website . ^{,/ .1i}

a^

1.. Name in full (in block letter)

1. Father's/Husband's name ---------
   
   
2. Address :-----------
   
   

⁽ⁱ⁾ Present address (for correspondence): -------

E-mail address ------Mobile _No. ------

(ii) Permanent address:

1. Date of birth ----_Age (According to Matriculation Certificate) (Enclose copy)
   
   
2. Are you a bonafide resident of Chhattisgarh Yes/No ^{(if "Yes" please} attach a copy of Domicile Certificate)
   
   
3. ^Place of birth ^(with name of Village /city, District and state) ---------
   
   
   1. (a) Mother tongue
      
      
   2. ^(b) Other language (s) which the applicant can speak read and write fluently
4. ^{Category (UR-Un Reserved} SC-scheduled Caste/ ST Scheduled Tribe/OBC-Other Backward Classes.
   
   
5. lf you are Disabled, Type of disability (please enclose a certificate _{from competent authority)}
   
   

^{(lf belong} to SC/ST/OBC Categorv, please enclose a certificate from competent authority) 10. Examinations passed : (please enclose copies of certificate/degree & marks-sheet/Transcript

of the examination)
Exa m inations	Name of	Name	Division	Percenta	ncrosure	Numoer
	the	of	o bta i ned	ge
	degree/ diploma	the U n ive rs ity /lnstitut		of marks/ OGPA obta i ned
		e
Hish School
Higher Secondary/
lntermediate/pre
U n ive rsity
Bachelor degree

Doctora I deeree Any other examination (s)

1. Whether Qualified National Eligibility Test (NET) Conducted by ICAR _/UGC (Enclose copy of Certificate for proof)
   
   
2. Academic Excellence (Enclose copy of certificates)
   
   

(i)

Medal at UG/PG/PhD

(a)

Gold Medal ----------

(b)

Silver Medal---

(c)

Bronze Medal ----------

13. Publications : Research/Extensioll ( attach complete list in bibliographic form and reprints for proof)

Publication As first author As co-author (No.) (No.) ( Full length Research paper _/Review article Short notes i) Published abstracts in seminars

(iv)

Popu la r/Extensio n a rticle

(v)

Va rieties/Tech no I ogy _I P are nt d eve lo ped/d issem i n ated

L4. Experience : As RA/RF/JRF/TA lFarm Manager/Subject Matter Specialist in any University/ R& D organization of repute/Central state Govt. etc. ( ln reverse chronological order, sta rt ^from the latest position held. (Enclose copy of appointment order/experience certificate for

proof)

5.N. \ame of the post Organization Period (from-to) xperience yearf month reld

Iotal

l./

1.5. Performance in extfa-curricular activities-NCC/NSS/ Games and Sports/Cultural (lnter University Level) enclosed copy of certificate for proof.

(i)

(ii)

(iii)

16. Additional Remarks, if any :

DECLARATION

I declare that the entries made in this application form are true and correct to the best of my knowledge and belief.

Place----

Dare------Signature of the candidate

Remarks of the present employer

(ln the case of those who are already in service)

The applicant Shri/Ku./Smt./Dr.

-ls holding a permanent/ temporary post of ---------in the scale of pay Rs.-------------and his/per present basic pay is Rs.----------------per month. His/Her application is forwarded and he/she will be relieved in case he/she is selected for the applied for.

Place------Date Signature Designation of Officer (with official sea!)