NATIONAL INSTITUTE OF TECHNOLOGY PATNA

PATNA-800 005 (BIHAR)

Application Form for Technical Assistant, Junior Engineer (Elect.)

Advertisement No. NITP/Rect./01/2016

To

Self attested
photograph

The Director
National Institute of Technology Patna
Ashok Rajpath
Patna- 800 005 (Bihar)
Post Applied for

DD Number

Department

Amount & Date

Name of issuing bank

1
2
3

5
6
7

8
9

10

Name in Full (In Block Letters)

Fathers Name/Husbands Name
Date of Birth
Day
(Attach self attested copy of Matriculation
Certificate in proof of date of birth
Age as on 26.04.2016
Year

Religion
Nationality
Category (SC/ST/OBC/PwD/GEN)
(Attach duly self attested certificate for
the Category claimed)
Type of disability with percentage
(if applicable)
Permanent Address with PIN Code

Correspondence Address with PIN Code

e-mail address & Mobile No.

Month

Year

Month

Days

11. Academic Qualification:- (Attach self attested copies of certificates & Marks-sheets):
Matriculation onwards
Name of
Exam
Passed
10th

Name of
School/College/Institute

Name of
Board/University

Year of
Passing

% of
Marks
obtained

Remarks

12th
Diploma
Bachelors
Degree
Others
(if any)
12. Experience (if any) ......
(Attach copy of Certificate)
Yes/No

13. Whether employed or not:

If yes, give details
Office/Instt./ Post
Firm
held

Adhoc/Reg./ From
Tem./
Pmt./Contract

To

Total

Scale of
Nature
Pay/Consolidated of
Pay
Duties

14. Working Knowledge of Computer (Yes/No): .

15. Special Qualification/Experience in Computer Knowledge

16. Name and address of two References:

2nd Reference

1st Reference
Name

Name

Position

Position

Address

Address

E-Mail

E-Mail

Phone No.

Phone No.

E-Mail Address

E-Mail Address

17. Any relevant additional information ...

18. Details of enclosures in support of information mentioned above
1)
2)
3)
4)
5)
6)
7)
Declaration
I do hereby declare that all statements made in this application are true, complete and correct to
the best of my knowledge and belief. I understand that in case any particular information
furnished by me is found to be false/incorrect/incomplete, my candidature is liable to be rejected
or cancelled and even after appointment, if it is found to be false or incorrect, my services are
liable to be terminated without any notice.

Signature of applicant
Place:
Date: .