APPLICATION FORM For The Post of Member Secretary, Uttarakhand Environment Protection & Pollution Control Board For Office Use 1. No. 2. Date of receipt (To be filled by the candidate in his/her own handwriting or typed) (Note: Where the space is not adequate in the application form, the information may be given on separate sheets as annexure) 1. Name of the Candidate (in block letters as per official record): 2. Name of Father/Husband/Mother: 4. (a) Present address: (b) Permanent Address: (c) Phone No./Fax No./E-mail id if any: 5. Date of Birth: (In numbers and in words, as per Official records) 6. Nationality: 7. Category: General/SC/ST/OBC: 8. Academic Qualifications: (Starting from High School) Sr. No. Examination Year of Passing Division Percentage of Marks Specialisation if any Name of the Board/ University 9. Professional Experience: 10. Academic Prizes/Honours: 11. Details of Research Projects Undertaken (a) Details of Completed Projects : 12. Details of Publications : (a) Books : (b) Research Papers Published : Single/Double/Multiple Authors Full Paper/Technical Note/Discussion (i) Journals : (ii) Conferences: National/International: (c) Technical Reports Sr. No. Designation Pay Scale Period of Employment Nature of Duties From To Note: Attach a separate sheet giving the names of the authors, title of papers in the Journals or Proceedings and year of Publication. Also submit 3 copies of your two research papers, which you consider as your Major Contribution. 13. Membership of Professional Societies National : International : : 14. Interests and Hobbies : 15. Participation in the Administrative/Academic Work: 16. Basic Pay and Total Emoluments, If you are in employment : 17. Were you at any time convicted or was any Disciplinary action taken against you? If so, give details. 18. Any other relevant information: 19. Please give the Names and Addresses of Two Referees who are aware of your Academic Performance or Professional Experience. 20. Details of Administrative/Academic/ Financial Administration If the space is not sufficient, please attach separate sheet(s). Note: Please attach copies of certificates of academic qualifications, experience and other supporting documents along with a list of enclosures. DECLARATION I hereby declare that information furnished above is true to the best of my knowledge and belief. If at any time I am found to have concealed any material information or given any incorrect data, my appointment, if made, may be terminated without notice or compensation. Date: Place: Signature of Applicant
