ACADEMIC STAFF COLLEGE

JAMIA MILLIA ISLAMIA, NEW DELHI 110025 PHONE No. Tel 011 -26926049 & Tel FAX: 011-269 26051 APPLICATION FO RM
We b Si t e : ht t p:/ / j mi .a c.i n/ a b outja mia / ce nt r e s/ a ca de mi c - sta f f/ int r oduc tio n
Email Id: dir.ascjmi@rediffmail.com, mkhan@jmi.ac.in

Orientation Programme: Refresher Course: 1. 2. 3. 4. 5. 6. 7. 8. Name of the Participant (BLOCK LETTERS) Fathers/Husbands Name Date of Birth Sex Qualification Whether belongs to Designation : .. : .. Photograph : .. : Male : PG : S.C. S.T. Female MPhil OBC PhD Minority General

: .

9.

Residential Address : (BLOCK LETTERS) .. Pin Code: . Phone No.: .. Name and Address of Institution & University : ... Pin Code: .. Phone No.: Adhoc Promotion .

Email ID:............................................................................. 10. Nature of Appointment : Permanent Temporary 11. Date of Joining : 12. Teaching Experience (in Years) : 13. Subject(s) of Teaching (i) (ii) Orientation Programme Refresher Course : Confirmation ..

. . . . : Dated Yes Year Year .. .. No

14. Have you attended any Orientation / Refresher Course(s) earlier? If yes give details. :Name of ASC :Name of ASC

15. Do you require Guest House accommodation during the programme? 16. Bank Demand Draft No. .. Drawn on ...

..

Note: Please enclose a Bank Demand Draft of Rs. 250/- (Two Hundred and Fifty only) as Application Processing Fees in Favour of the Registrar, Jamia Millia Islamia, New Delhi Date .. Place .... Signature.....

1. Recommended and forwarded. 2. Certified that he/she will be relieved from duties by the Institution and will be treated on duty leave for the programme period as and when called to participate in the course. 3. Certified that this University/ College is included in the list of colleges under Section 12(B)/ 2(F) (1956) of the UGC Act.
Principal/ Head of Institution

with seal