U. G. C. ACADEMIC STAFF COLLEGE PHOTO UNIVERSITY OF KERALA (to be affixed) KARIAVATTOM CAMPUS, THIRUVANANTHAPURAM -695 581 Phone : 0471- 2418989 Fax : 0471-2412267 Email :
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Web: ugcasc.keralauniversity.edu Application Form for Admission of REFRESHER COURSE/ ORIENTATION PROGRAMME Subject From .......To........... I PERSONAL INFORMATION 1. Name of the teacher :......................... (in block letters initials after name) 2. Date of Birth & Age :......................... 3. Sex : Male/Female 4. Educational Qualifications :......................... 5. Community : SC / ST /Others 6. Residential Address :......................... ......................... ...............Pin Code...... Phone No.(with STD Code) .............. 7. Mailing Address : ........................ ........................... ........................ II DETAILS OF EMPLOYMENT 1. Designation : Lecturer / Sr. Lecturer / Sl. Gr. Lecturer 2. Subject : ........................ 3. Basic pay & Scale of Pay : ........................ 4. Address of the College / University : Dept. of ..................... .......................... .......................... 5. Name of the Affiliating University : .......................... III DETAILS OF TEACHING EXPERIENCE 1. Date of first Appointment : .......................... 2. Date of regular Appointment : .......................... 3. Status of Appointment Permanent / Adhoc / Temporary 4. Teaching Experience : ............Years .........Months (College / University) 5. Classes handling : Degree / PG 6. Research Guidance : M. Phil / Ph. D Details of Courses Attended Course Institution Period From To Orientation Programme Refresher Courses 1. 2. 3. I hereby undertake to participate in the Seminar and to do the project work during the course under the guidance of resource persons and to accept the hospitality rendered by Academic Staff College apart from following the rules and regulations of the ASC. The particulars given above are true to the best of my knowledge and belief. Place : Date : Signature of the Applicant CERTIFICATE OF RECOMMENDATION FROM THE PRINCIPAL I recommend Dr. / Mr. / Ms........................... Lecturer / Sr. Lecturer / Sl. Gr. Lecturer (Strike off which ever is not applicable) ........ ......................................... for the Orientation Programme / Refresher course in ..................He /She will be relieved on time to participate in the above course at Academic Staff College, if selected. Certified that this College is affiliated to ..................... University for the last five years. Also certified that the details of courses attended by him/her are verified and found correct. Place : Date : Signature of the Principal /HOD With Office Seal For Office use only Selected for the .......ORIENTATION PROGRAMME / REFRESHER COURSE in ....... commencing from ............................ Place : Date : Director cum Professor
