STATE BANK OF INDIA APPLICATION FOR CONSULTANTS APPLICATION CODE

(For application codes, refer table1 in the information brochure):

MO

1. 2.

3.

4. 5. 6.

Full Name (In block letters) : Sh. Vidhya Prakash Johri Present address for communication (In block letters) Address Line 1 : 401, SIMSR Hostel, Staff Quaters Address Line 2 : Somaiya College of Management City : Mumbai State : Maharashtra Pin code : 400077 Mobile No. : 9969047992 Landline No. (With STD Code) : Fax No (with STD code) : Email Id : era.johri@gmail.com Date of Birth (DD-MM-YYYY) : 10 April 1943 Age as on the date of : 68 application Nationality : Indian Fathers / Husbands Name : Late Sh. Gopal Nayaran Saxena Academic / Professional Qualifications (Self attested copies of certificates to be enclosed): Note: For Academic, mention only graduation & above # Degree / Course Name of University / Institution Bachelor of Engineering a. University of Jodhpur (Mining) First class Mine Managers Certificate (unrestricted) under b. Metalliferous Mines Metalliferous Mines Regulation, 1961 Regulation, 1961,India to manage large Open Pit and Underground Mines. Registered with government of India as recognized person for preparation of c. Mine Plan, Review plan, eco friendly plan, mine closure plan etc. for new and existing mines. Authorized to prepare d. Environment Plan e. f. g.

h.

7.

Total work experience in years : 30 years Note - The details of the work experience are to be enclosed in the following format in separate sheet(s) along with this application form. Also enclose the relevant supporting documents (self attested) pertaining to the work experience. From Name of the Details of To Year Position(s) Held Year Organization Assignment

8.

9.

Other Professional Engagements, if any Note - The details of Other Professional Engagements, if any, are to be enclosed in the following format in separate sheet(s) along with this application form. Also enclose the relevant supporting documents (self attested). Name of the Brief role description Company / Body / Period & work done Committee Directorship in any companies Membership of any Professional Bodies/ Committees Particulars of papers, if any, published/ presented in professional forum Note - The details, if any, are to be enclosed in the following format in separate sheet(s) along with this application form. Also enclose the relevant supporting documents (self attested). Forum Date / Period Topic Assignment(s) similar to the one applied for, if any, already engaged in Note - The details, if any, are to be enclosed in the following format in separate sheet(s) along with this application form. Also enclose the relevant supporting documents (self attested). Name of Institution/Company Nature of Assignment

10 .

11 .

References (Provide 2 references) Reference 1 Name Organization Designation Complete Address for Communication Mobile No. Landline No. (With STD Code) Fax No. (With STD Code) Email Id Reference 2

DECLARATION - I 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 the event of any information being found untrue or incorrect at any stage or my not satisfying any of the eligibility criteria according to requirements laid down, my candidature/assignment is liable to be cancelled.

Place: Date:

Signature: Name of the Candidate: