Society for Applied Microwave Electronics Engineering & Research

(SAMEER)
Plot-L2, Block-GP, Sec-V, Salt Lake Electronics Complex, Kolkata- 700091

APPLICATION FORM
(TO BE FILLED IN BY APPLICANT IN BLOCK LETTERS ONLY)

Advt.No SMR(K)/Rec-1/11-12
Post Applied for :__________________

Affix Recent
Passport
Size Photograph

1. Name in full(Shri/Smt/Km) : _______________________________________________

-----------------------------------------------------------------------------------------------------------------------2. a) Fathers name: __________________________ b) Mothers name: _________________________________
3. a) Date of Birth:
(in Christian era in figures)

___________________19 _______
Date
Month
Year

b) Age as on closing date mentioned in Advt.: _________Years _________Months _________ Days

4. a) Sex (Male/Female) : _________________

b) Marital Status : ________________________________

5. Nationality: _____________________________
6. Reservation Category (SC/ ST/OBC): _____________________6 (a) Religion :_______________________________
(attach certificates if applicable)
7. Type of Present Employment, if employed (Central / State Govt / PSUs/Others): _________________________
(If employed Central /State Govt./PSU etc. submit N.O.C alongwith your application)
8. Address for correspondence(with Pin Code)
(Tele No., Mob. No., Fax & e-mail, if any)

_____________________________________________________

9.Permanent Address (with Pin Code)

_____________________________________________________

(Tele No., Mob. No., Fax & e-mail, if any)

10.Nearest Railway Station

_____________________________________________________
_____________________________________________________

11.Educational Qualifications #:
----------------------------------------------------------------------------------------------------------------------------------------------------------*Exam
University/ Date of Date of
Subject Specialization **Percentage Division
Rank/Position
passed
Institution/ Joining Passing
in which as reqd. in
of Marks
in the Univ.
Board
degree is advt. (if any)
awarded
-----------------------------------------------------------------------------------------------------------------------------------------------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------- In chronological order from X Standard (SSLC/HS/HSC) onwards, ** In case of CGPA/CPI, please give
marks in percentage also along with the conversion formula, # Specify the gap with reasons in
Education career, if any.

12. Professional Training :

-----------------------------------------------------------------------------------------------------------------------------------------------------Name of organization
From
To
Details of Training

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

13.
Research /Project Work (To be filled up by Scientist -B only) :
Title of the project /Dissertation /Thesis No of paper published (separate sheet may be attached) :

14.

Have you qualified GATE/NET(JRF)/NET (To be filled up by Scientist- B) :

a) If yes, give name of Test & Year (with percentile for GATE) :
b) if registered for a higher degree, please indicate Title of degree, University, date of registration and
likely date of completion

15(a). Employment Record* (Attach separate sheet in following format, if necessary):--------------------------------------------------------------------------------------------------------------------------------------------------------Name &
Period of
Designation
Scale of
Detailed
Reason for leaving
address of
service
of the post
pay of
description
employer/
From
To
held
each post
of work
Orgn/Institution
--------------------------------------------------------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------------------------------------------------------* Specify the gap, if any

16. Present Basic pay:

Total Emoluments:

17. Are you under any contractual obligations to serve Central/State Govt./Any other Public Sector Undertaking
or Autonomous body and if so, give details :
(attach NOC if applicable)

18. Have you been interviewed for any recruitment/selection by SAMEER during the past one year?
If yes, give particulars:
------------------------------------------------------------------------------------------------------------------------------------------------------Sr
Particulars
Name of Posts &
Date of
Result
No.
(eg. Date of Advt, Advt. No.)
Discipline
Interview

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

19. Give two referees name & address and attach certificate from them: ________________________________
(Not related to the candidates) (Gazetted Officers/Professors of
reputed academic Institutions/Public Sector Executives etc)
________________________________

20. Any other information you may wish to add, including extra curricular activities (use separate sheet if necessary).

Declaration
I declare that the foregoing information is correct and complete to the best of my knowledge and belief
and nothing has been concealed/distorted. If at any time, I am found to have concealed/distorted any material
information, my appointment shall be liable to summary termination without notice. If offered appointment, I will
join on specified date and subsequently, take up duty in the discharge of SAMEER assignments anywhere in
India as and when required.

Place:
Date:

------------------------------------------Signature of Candidate

Note : (Please use a4 size paper only for application and other testimonials)

SUMMARY
(Use Separate Sheet)
Advt. No. :

Discipline :

SMR(K)/Rec-1/11-12

Post :
Sr. No.
Name :

DOB:

Nationality:
Month Year

Category:

SC/ST/OBC/Gen

Age as on Closing Date:

Central/State Govt./Armed Forces/ PSUs/Others:

Exam

University

Subject

Month Year

%age

Div/Gde

Essential Qualification (EQ)

Highest Qualification (HQ)

Qualified :

GATE

NET(JRF)

NET

Year:

Score:

Postal Address:
City:
Tele. No.
(with STD code)

E.Mail :

Mobile:

PIN:
FAX:

University Rank