Old Mahabalipuram Road
Thalambur
Chennai - 603 103
Tamil Nadu, India
Phone : 044 - 2743 5528, 2743 5627
Fax : 044 - 2743 5769
Email :
Website : www.act.edu.in /

Application Form

CONFIDENTIAL

App No (office use only)

Please type or complete the application form in DARK INK.

Please do enclose curriculum vitae also with this.

Vacancy details

Job applied for
Department / Job Reference No

Personal details:

Name / Title
Age / Date of Birth
Present Address
Pin code
Telephone : Home / Office
Mobile Phone / Fax
Email address
Permanent Address
Pin code
Marital Status

Present or most recent employment

Please give details of your current or most recent employment

(If you have more than one job, please provide details on a separate sheet)

Name of Employer
Address
Pin code
Date of appointment / Job Title
Salary
Brief summary of main duties
Date of leaving (if applicable) / Period of notice
Reason for leaving (if currently unemployed)

Additional employment

Do you have any employment which will continue if you are appointed? Yes £ No £
Please provide details if Yes
Previous employment

Please list your previous employment starting with the most recent first.

Please continue on a separate sheet if necessary.

Date from / Date to / Employer / Job Title / Scale of Pay /
Salary / Reason
for Leaving
M / Y / M / Y
Qualifications

Please give details of Educational and Professional qualifications that you have gained or are currently working towards, which are relevant for the job for which you are applying. (In Reverse Chronological Order)

Date from / Date to / Degree / College / University / Full or
Part-time / Grade/Class
M / Y / M / Y
Training programs/ Seminars / Conferences organised

Please list any program(s) which you have organised which are relevant to the job.

Date / Program Title / Brief Details

Please continue on a separate sheet if necessary

Training programs / Seminars / conferences attended

Please list any program(s) which you have attended which are relevant to the job.

Date / Program Title / Brief Details

Please continue on a separate sheet if necessary

Technical / Research Papers Published

Please list any technical / research papers published in National / International level Journals which are relevant to the job.

Title of Paper / Name of Journal / Brief Details

Please continue on a separate sheet if necessary

Technical / Research Papers Published

Please list any technical / research papers published in National / International level Conference which are relevant to the job.

Title of Paper / Name of Conference / Brief Details

Please continue on a separate sheet if necessary

Professional Membership
Professional Body / Type of Membership / Date Admitted / Expiry Date
M / Y / M / Y
Software Skills
Books Published
Title and Publisher / Year of Publication
Support Information

Please give details of relevant skills, knowledge and experience gained in either paid or unpaid work.

Please continue on a separate sheet if necessary

References

Please give details of two people who are willing to give you a reference. One of these must be your present or most recent employer.

Name / Relationship to you
Address
Tel No
Fax No / E-mail
Job Title
Can we take up a reference at this stage? Yes £ No £
Name / Relationship to you
Address
Tel No
Fax No / E-mail
Job Title
Can we take up a reference at this stage? Yes £ No £

Declaration

I confirm to the best of my knowledge that the information given on this form is accurate and that I have not omitted any facts, which may have a bearing on my application for employment.

Signature / Date