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									Grams:Manovikas                                                  Tel.No.27751741-745
Website:www.nimhindia.org.                                       Fax No.040-27750198

             NATIONAL INSTITUTE FOR THE MENTALLY HANDICAPPED
               (Ministry of Social Justice & Empowerment, Govt. of India)
                  MANOVIKAS NAGAR, SECUNDERABAD 500 009
                              An ISO 9001:2008 Institution

     APPLICATION FOR THE POST OF LECTURER IN REHABILITATION PSYCHOLOGY
  (SPECIAL RECRUITMENT DRIVE FOR FILLING UP OF THE POST RESERVED FOR 'ST' CATEGORY)
  (Please read the general terms and conditions before filling the application form)

                                               Application No.
                                                                  (For office use only)
Employment Notice No. 01/2011 , Dated:___________ .

                                                                     Pl ea s e a f f i x re ce n t
                                                                      at t e st e d p ass p o rt
                                                                           p h ot og ra p h




Particulars of the attached D. D : Name of Bank: ________ D.D. No._______Dt:____


1. Name:(In Block Letters) :______________________________________________

2. Date of Birth : ____________ 2 (a). Age as on 05.09.2011 : _________________

3. Address for Communication :

  Building/H.No : _____________________________________________

  Street/Colony : _____________________________________________

  City/Town :         ______________________________________________

   State        :     ______________________________________________

   Pin              : ______________    STD Code: __________________

   Phone :           ______________     Mo bile:    _________________

   *Email :       ______________________________________________
  (* E-mail is essential to be quoted)
4. Permanent Address:

  Building/H.No : _____________________________________________

   Street/Colony : _____________________________________________

   City/Town :       ______________________________________________

   State        : ______________________________________________

   Pin           : ______________        STD Code: __________________

   Phone :           _______________     Mo bile:     _________________

   *Email :       _______________________________________________
   (* E-mail is essential to be quoted)

5. Married:                   Single :

6. Are you seeking reservation as SC/ST/OBC/Physically handicapped?
   (Attach certificate)

7. Nationality of:

   a) Applicant :______________

  b) Father :        ______________                 Name :___________________

  c) Mother : ______________                        Name : ___________________

  d) Husband/Spouse :______________                 Name: ___________________

8. Father`s/ Husband`s:

   a) Name in full      :         ___________________

  b) Present Postal address : ___________________
      ( if dead give last address) ___________________
                                   ___________________
c) Profession (if in service : ___________________

   give designation and office ___________________
   address)                    ___________________
9. Mother`s :

  a) Name in full    :           ___________________

  b) Profession (if in service : ___________________
     give designation and office ___________________
     address)                    ___________________


10. Educational Qualification: (from Secondary Examinations onwards) (Attach
    attested copies of certificates)

  Examination         Name of the      School/ college Division with Year of   Subjects
    passed          University/Board      attended     percentage of passing
                                                          marks
                                                         obtained
11. Technical Qualifications: (Attach attested copies of certificates)


  Examination          Name of the        School/ college Division with Year of    Subjects
    passed           University/Board        attended     percentage of passing
                                                             marks
                                                            obtained




12. Experience ,if any : (Attach a separate sheet, if necessary)



Employer’s    Designation    Regular/      Scale of     Basic  Total        Length of    Nature
Name and                    Temporary/       pay         pay emoluments     experience    of
 Address                    Permanent/                                                   work
                             Contract                                      From     To
13. Referees: (Attach three reference letters)

 (These should be persons resident in India and holders of responsible position,
and should be intimately acquainted with applicant’s character and work, but must
not be relations. Where the candidate has been in employment S/he should either
give his present or the most recent employer or immediate superior as a referee
or produce a testimonial from him in regard to his/her fitness for the post for
which S/he is an applicant.)

i) a) Name :__________________            ii) a) Name :         __________________

  b) Posit ion :__________________               b) Posit ion : __________________

  c) Address :__________________              c) Address :      __________________
              __________________                                __________________

   d) E-ma il :__________________             d) E-ma il :       __________________

  e) Phone No. :__________________                e) Phone No. :_________________

  f) Fax :      __________________                f) Fax :      __________________

iii) a) Name :__________________

   b) Position :__________________

  c) Address :__________________
              __________________
  d) E-mail : __________________

  e) Phone No. :__________________

  f) Fax :        __________________

14. Nearest Railway Station :

15. (a) Post held, if any, at the time of sending the application with date of
        appointment (State whether permanent, or temporary) :

     (b) Name of Employing Authority :

16. Minimum basic pay in scale of the post applied for expected :

17. Indicate the time you will require to join, if selected :

18. Number of literacy, cultural or other activities (e.g. achievements in sports
    etc. in which the applicant is interested and distinctions, if any, obtained in
    the same :

19. Are you an Ex-Serviceman/Disabled Defense Personnel/Dependent of
    Defense Personnel killed in action ? If so, details of Certificate (e. g. No.,
    Date and Issuing Authority) :
20. Are you a Physically Handicapped person ? If so give details of Medical
    Certificate issued by Competent Authority:

21. Have you been debarred or punished for adopting unfair means in any
    examination by the institution/Board or University? If so, please specify :

22. Have you been imprisoned by any Court of Law for any criminal or
    civil act? If so, give details:

23. Are you related to anybody employed in NIMH, Secunderabad presently.
    YES/NO:
    If YES, indicate (i) Name of employee
                    (ii) Nature of Relationship:


24. Would you like to treat your personal information in this application
     with enclosures as confidential for RTI Act 2005 provisions (Write Yes or No)
     _____________________

25. Any other information:


___________________________________________________________________

                       APPLICANT`S DECLARATION

(a) I hereby declare that the information provided in this form is true to
    the best of my knowledge and belief. I have satisfied myself that I fulfill all
    the eligibility requirements.

(b) I shall submit myself to the disciplinary jurisdiction o f the competent
    authorities of the Institute who may be vested with the authority to
    exercise discipline under the Act/Statutes/Ordinances and the Rules that
    have been framed by the Institute.

(c) I agree that the decision of the Institute on all matters will be final and
    binding on me.

(d) I understand that my association active or passive with any unlawful
    organizations is forbidden.

                                                          ______________________

Date:_________                                           Signature of the Applicant

_____________________________________________________________________
          (For candidate in Government/Statutory Bodies Service only)

Forward ed with the remarks that the facts stated in the above, application
have been verified and found correct and this Institution/Organization has no
objection to the candidature of the applicant being consider for the post
applied for. It is certified that no vigilance/disciplinary case is pending or
contemplated or initiated against the official. The integrity of the official is
certified.

                                                                    Forwarded:

                                                          __________________

Dated: _____ ____                          Signature of the Forwarding authority

                                           Designation :____________ _______
                                           Address     :___ ________________
                                                       ____________________
                                           Pin Code :___________________
                                       Tele phone/Fax :___________ ________
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Grams:Manovikas                                                     Tel.No.27751741-745
Website:www.nimhindia.org.                                          Fax No.040-27750198

             NATIONAL INSTITUTE FOR THE MENTALLY HANDICAPPED
               (Ministry of Social Justice & Empowerment, Govt. of India)
                  MANOVIKAS NAGAR, SECUNDERABAD 500 009
                              An ISO 9001:2008 Institution


GENERAL TERMS & CONDITIONS


(a) The applicant must be a citizen of India

(b) The candidates selected on direct recruitment will be governed by the provisions of the
    New Pension scheme introduced by the Government of India w.e.f.01.01.2004.

(c) The applicants serving in Government/Public Sector Undertakings /Autonomous
    bodies/NGOs must send their applications THROUGH PROPER CHANNEL.

(d) The envelope containing the application should be superscribed as Application for the post
    of 'Lecturer in Rehabilitation Psychology'.

(e) The filled in applications should reach latest by 5th September, 2011 by 05.30 PM to the
    Director, NIMH at the address given above. Applications received late/incomplete will not
    be considered.

(f) Mere possessing the Essential Qualifications will not entail any candidate a right to be
    considered eligible for the post. The final list of candidates called for interview/written test
    is based on the short listing candidates by a duly constituted Screening Committee .

(g) Relaxation in upper age limit is applicable upto 15 years to ST/OH candidates as per the
    norms of GOI.

(h) The cut off date for calculating the age is the last date for receipt of applications.

(g) This advertisement notification and application form are available in our website
     www.nimhindia.org.

(h) No correspondence in this matter is entertained.
y Magistrate)

        (ii)    Revenue Officer not below the rank of Tehsildar.
        (iii)   Sub-Divisional Officer of the area where the candidate and / or his family normally
                resides.

12.     Canvassing in any form will lead to disqualifications.

13.     Extra Sheet should be added wherever space is insufficient.




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