(12D)

Online Application FormJoint CSIR-UGC Test for JRF and Eligibility For Lectureship, NET - 23-12-2012 [Council of Scientific & Industrial Research - HRD Group, Examination Unit]
1. RollNo(To be filled by Office Only) 2. Application No.

12D694917
3. Applied For 4. Subject 5. Exam Centre 6. Meduim of NET Exam(As applicable) 7. Candidate Name 8. Sex 9. Father/Mother/Husband Name 10. Date Of Birth 11. Age As On 01-07-2012 12. Category 13. Physically/Visually Handicape(PH/VH) 14. If VH, Do You Want Scribe's Help : 01 - JRF : 3 - LIF - LIFE SCIENCES : 20 - PUN - PUNE : 02-ENGLISH : NUPUR SHANTARAM NAGAVEKAR : FEMALE : FATHER -> SHANTARAM GAJANAN NAGAVEKAR : 04-01-1990 : 22 Y, 5 M, 28 D : GEN : NA : NA

15. Write your name and complete Mailing Address. Name: Address: NUPUR SHANTARAM NAGAVEKAR FLAT NO.-12, PLOT NO.-80,MAHESHWAR C.H.S. LTD.,R.A.K. MARG, WADALA MUMBAI 400031 MAHARASHTRA Signature of Candidate ------>

City: Pin: State:

16. Permanent Address Name Address 17. Email : NUPUR SHANTARAM NAGAVEKAR : B-5, PLOT NO.-36,SHAHAJI GANJ,SHIVAJI PARK, State : MAHARASHTRA : nupurnagavekar@gmail.com City : KOLHAPUR Pin : 416002

18. Qualifying Degree

: M.TECH

[Candidates enrolled for M.Sc. or having completed 10+2+3 years of qualifying examination as given in column 18, may apply under Result Awaited (RA) category] 19. If Result Awaited 20. Year Of Appearing in Final Exam (a) Year Of Passing : NA 22. If enrolled in MS-PhD program (a) Year of enrollment (b) Year of passing bachelor degree (c) Division/Grade : RA : 2013 (b) Division : NA : NO : NA : NA : NA (If Result Awaited) (c) Mark Obtained (%) : 0 %

21. Give detail of Final Exam Result (If not Result Awaited)

(d) Marks Obtained (%)

:0 Application No: 12D694917

23. Specialization : (a) Specialization Code : 309 24(a) University/Institute Code (b) University/Institute Name (b) Specialization Subject Name : FOOD BIOTECHNOLOGY : 999 : INSTITUTE OF CHEMICAL TECHNOLOGY, MUMBAI

DECLARATION I, NUPUR SHANTARAM NAGAVEKAR, hereby declare that all statements made in this application are true, complete andcorrect to the best of my knowledge and belief and in the event of any of the information being found false or incorrector any ineligibility being detected before or after the test my candidature is liable to be cancelled and action initiatedagainst me.I have submitted only one application for this test.I further declare that I fulfill all conditions of eligibility regarding Age limits, Educational qualifications etc. prescribed forthe test.I also declare that I have never been convicted by any court of law.I declare that I have gone through the conditions attached to NET and shall abide by the same.I have enclosed the attested copies of certificate of being SC/ST/OBC/PH/VH (Physically or Visually handicapped), (strike which is not applicable).I understand that my application will be rejected summarily if found incomplete/ineligible, and no correspondence will be entertained by CSIR in this regard. Date:Place: Signature of the Candidate. ATTESTATION(For 'RA' Category Only) I certify that the information given by the candidate Shri/Smt/Kum NUPUR SHANTARAM NAGAVEKAR has been verified by me with reference to records.Also this is certifiied that the candidate is enrolled for M.Sc. or having completed 10+2+3 years of (BS-4 year/BE/B.Tech./B.Pharma/MBBS/Integrated BS-MS or equivalent degree & is eligible to appear under 'RA" category as laid down in the eligibility criteria of CSIR-UGC NET December 2012. (Strike which is not applicable) Signature of the Head of Dept./InstituteRubber stamp/seal Name:Designation: NOTE : (Attestation should be signed by the Head of the Dept. or Institution where the candidate has appeared OR will be appearing in the above notified Qualification/Degree Examiniation as applicable). 25. Challan Detail. Name of the Bank Branch Code Amount in Figure(Rs.) Challan Date

:MATUNGA B : 1858296 : FOUR HUNDRED : 8976411303 Signature of Applicant Note:Please send hard copy of this ONLINE submitted application form duly signed with recent passport size Black & white photograph along with a copy of original challan (fee deposit receipt) meant for CSIR(Examination Unit) with required certificate(s) by U.P.C./ordinary Post only, as notified in the Employment News/Website by arranging your own envelop (5X11) superscribing your subject code, application no., and centre code which should reach to the Sr. Controller of Examination, Examination Unit, Human Resource Development Group, CSIR Complex, Library Avenue, Pusa, New Delhi-110012 on or before 24.09.2012 (01.10.2012 for remote areas).Please do not staple the hard copy of the Application form & enclosures. Branch/City Journal No. Amount in Word(Rs.) Phone

: : : :

INDIAN BANK 018 400 17/09/2012

Cut and Paste following address on your own envelop(5X11)

(Application for Joint CSIR-UGC Test for JRF/LS (NET), December, 2012) [3 - LIF | 20 - PUN | 02-ENGLISH]

To, Sr. Controller of Examinations Examination Unit, Human Resource Development Group CSIR Complex,opposite Institute of Hotel Management, Library Avenue

Pusa, New Delhi-110012