ACADEMIC STAFF COLLEGE

UGC-ACADEMIC STAFF COLLEGE
JAWAHARLAL NEHRU UNIVERSITY

New Campus, New Delhi 110067

Tel: 26717532, 26717566, 26717569 Fax: 26717532

Email: ascjnu@iname.com

APPLICATION FORM

Please print out this form and post it to us through ordinary mail (snail mail).

Orientation / Refresher Course in ___________________________

(Please see list of courses offered by the ASC, JNU)

Photograph

Name in full (IN BLOCK LETTERS) Dr/Mr/Ms:________________________

____________________________________________________________

Date of birth : ___________________________________________

Category : SC/ST/OBC/GENERAL SEX : MALE/FEMALE

Institutional/College/University Address: __________________________

______________________________________________________________

____________________________ STATE: ______________ PIN ________

Mailing Address:_______________________________________________

______________________________________________________________

____________________________ STATE: ______________ PIN ________

Contact ph. (with STD code): _____________ email: __________________________

Educational Qualifications:

Examination	Subject(s) & Specializations	% age of marks / Grade	University	Year
Post-Graduation M.Phil. Ph.D.

Title of M.Phil and/or Ph.D. Theses (if any):___________________________

______________________________________________________________

Details of Employment (in chronological order):

Institution	Designation	Period		Nature of Duties
		From	To

Have you ever attended any Refresher Course / Orientation Course previously?

NAME OF COURSE	ASC WHICH CONDUCTED THE COURSE	WHEN THE COURSE WAS HELD

What are the subjects of your special interests?

Please attach a separate sheet listing your publications if any.

I hereby declare that the entries made in this application form are true to the best of my knowledge and belief. It is also certified that my college is included in the list of the colleges under Section 2(f) 12-B of the UGC Act.

Dated: Signature of Applicant

PLEASE BRING A RELIEVING ORDER FROM THE APPROPRIATE AUTHORITY AT THE TIME OF JOINING THE COURSE. NO ONE SHALL BE ALLOWED TO SIT IN THE COURSE WITHOUT A RELIEVING ORDER.

PROCESSING FEE

Please attach to this form a non-refundable processing fee of Rs 200 through an account payee bank draft in favour of the Finance Officer, Jawaharlal Nehru University, New Delhi, payable at the State Bank of India, JNU, Code No. 1624. On the reverse side of the draft please write the name of the course applied for, your own name and your address. We regret that cash/cheques/ P.O. etc. are not acceptable.

DRAFT NO.: ___________________________________DATE:________________

ISSUING BANK & BRANCH:___________________________________________

AMOUNT:

Certified that Mr./Ms.___________________________________________has been working in this College/University as lecturer in the pay scale of Rs.8000-13500/10,000-15,200 in (subject) __________________________________since_______________________________ We shall be happy to sponsor him/her if selected for the course to be conducted by the Academic Staff College, Jawaharlal Nehru University, New Delhi-110067.

Also Certified that this College is included in the list of Colleges under Section 2(f) 12-b of the UGC Act.

Signature of Principal/Registrar

Name__________________

Designation_________________________

Address____________________________________________________________________________

Office Seal

PLEASE NOTE: The last date for receipt of an application form is 60 days before the start of the course. Any application form is valid for 1 ½ years after its receipt. We process only those application forms which are accompanied by the processing fee (photocopies of the draft are not accepted).