SCHOOL OF PLANNING AND ARCHITECTURE: VIJAYAWADA

(An autonomous Institution of MHRD, Govt. of India)

Camp Office: Acharya Nagarjuna University, Nagarjuna Nagar,
District Guntur-522510, Andhra Pradesh
Application No.
(For office use only)

Application for Non-Faculty positions

Please read the general terms and conditions before filling the application form.

Please affix recent

attested passport
photograph

Advertisement No.______________________ , Dated:___________ .

Application form for the post of S.No [ ___ ] _____________________________________

Particulars of the attached D.D : Name of Bank: ___________ D.D. No. _________ Dt:_______

1.

Name: (In Block Letters)

:______________________________________________

2.

Date of Birth : _______________ 2 (a). Age as on 29.07.2011

3.

Address for Communication:

:_________________

Building/H.No :______________________________________________
Street/Colony :______________________________________________
City/Town

:______________________________________________

State

:______________________________________________

Pin

:______________

Phone

: _______________

*Email

: ______________________________________________

STD Code: __________________

Mobile: ______________________

(* E-mail is essential to be quoted)

4.

Permanent Address:
Building/H.No :______________________________________________
Street/Colony :______________________________________________
City/Town

:______________________________________________

State

:______________________________________________

Pin

:______________

Phone

: _______________

*Email

: ______________________________________________

(* E-mail is essential to be quoted)

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STD Code: __________________

Mobile: ______________________

5.

Married:

6.

Are you seeking reservation as SC/ST/OBC/Physically handicapped?

(Attach certificate)

7.

Nationality of:

8.

Single :

a) Applicant

:______________

b) Father

:______________

Name:___________________

c) Mother

:______________

Name:___________________

d) Husband/Spouse :______________

Name:___________________

Father`s/Husband`s:
a) Name in full

:___________________

b) Present Postal address

:___________________

( if dead give last address) ___________________

___________________
c) Profession (if in service

:___________________

give designation and office ___________________

address)
9.

___________________

Mother`s :
a)

Name in full

:___________________

b)

Profession

:___________________

(if in service give

___________________

designation and

___________________

office address)
10.

Educational Qualification: (from Secondary Examinations onwards) (Attach attested

copies of certificates)

Examination
passed

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Name of the
University/Board

School/
college
attended

Division with
percentage of
marks
obtained

Year of
passing

Subjects

11.

Technical Qualifications: (Attach attested copies of certificates)

Examination
passed

12.

Name of the
University/Board

School/ college
attended

Division with
percentage of
marks
obtained

Year of
passing

Subject

Experience ,if any : (Attach a separate sheet, if necessary)

Employers
Name and
Address

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Designation

Regular/
Temporary/
Permanent/
Contract

Scale of
pay

Basic
pay

Total
emoluments

Length of
experience
From

To

Nature of
work

13.

Referees: (Attach three reference letters)

(These should be persons resident in India and holders of responsible position, and should be
intimately acquainted with applicants character and work, but must not be relations. Where the
candidate has been in employment S/he should either give his present or the most recent
employer or immediate superior as a referee or produce a testimonial from him in regard to
his/her fitness for the post for which S/he is an applicant.)

i) a) Name

:__________________

ii) a) Name

:__________________

b) Position

:__________________

b) Position

:__________________

c) Address

:__________________

c) Address

:__________________

__________________
d) E-mail

:__________________

__________________
d) E-mail

:__________________

e) Phone No. :__________________

e) Phone No. :__________________

f) Fax

:__________________

f) Fax

iii) a) Name

:__________________

b) Position

:__________________

c) Address

:__________________

:__________________

__________________
d) E-mail

:__________________

e) Phone No. :__________________

f) Fax

:__________________

14.

Nearest Railway Station :

15.

(a) Post held, if any, at the time of sending the application with date of appointment (State
whether permanent, or temporary) :
(b) Name of Employing Authority :

16.

Minimum basic pay in scale of the post applied for expected :

17.

Indicate the time you will require to join, if selected :

18.

Number of literacy, cultural or other activities (e.g. attainment in sports etc. in which the
applicant is interested and distinctions, if any, obtained in the same :

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19.

Are you an Ex-Serviceman/Disabled Defence Personnel/Dependent of Defence Personnel

killed in action ? If so, details of Certificate (e.g. No., Date and Issuing Authority) :

20.

Are you a Physically Handicapped person ? If so give details of Medical Certificate issued
by Competent Authority:

21.

Have you been debarred or punished for adopting unfair means in any examination by the
institution/Board or University? If so, please specify :

22.

Have you been imprisoned by and Court of Law for any criminal or civil act? If so, give
details:

23.

Are you related to anybody employed in School of Planning and Architecture, Vijayawada
presently. YES/NO:
If YES, indicate (i) Name of employee

(ii) Nature of Relationship:

(i.e. Parent, Child, Sibling,
Cousin, Uncle, Aunt, Nephew
or Niece of self or of Spouse)

24.

Would you like to treat your personal information in this application with enclosures as
confidential for RTI Act 2005 provisions (Write Yes or No) _______

25.

Any other information:

-------------------------------------------------------------------------------------------------------------------------------

APPLICANT`S DECLARATION

(a)

I hereby declare that the information provided in this form is true to the best of my
knowledge and belief. I have satisfied myself that I fulfill all the eligibility requirements.

(b)

I shall submit myself to the disciplinary jurisdiction of the competent authorities of the
School who may be vested with the authority to exercise discipline under the
Act/Statutes/Ordinances and the Rules that have been framed by the School.

(c)

I agree that the decision of the School on all matters will be final and binding on me.

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(d)

I understand that my association active or passive with any unlawful organizations is

forbidden.

___________________
Date: _________

Signature of the Applicant

------------------------------------------------------------------------------------------------------------------------------(For candidate in Government/Statutory Bodies Service only)

Forwarded with the remarks that the facts stated in the above, application have been verified
and found correct and this Institution/Organization has no objection to the candidate of the
applicant being consider for the post applied for. It is certified that no vigilance/disciplinary case
is pending or contemplated or initiated against the official. The integrity of the official is certified.

Forwarded:

_____________________
Signature of the
Forwarding authority

Dated: _________

Designation :__________________
Address

:__________________
__________________
___________________

Pin Code

:___________________

Telephone :___________________
Fax

Page - 6 - of 7

:___________________

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