INDIAN COUNCIL FOR CULTURAL RELATIONS
AZAD BHAVAN, I.P. ESTATE, NEW DELHI- 110002

APPLICATION FOR EMPANELMENT WITH ICCR FOR DEPUTATION TO IT’ S CHAIRS ABROAD

(1)	Name in full: 		__________________________________________

(2)	Present address: 	__________________________________________

                              		__________________________________________

(3)	Permanent address: 	__________________________________________
        
      	__________________________________________

    	__________________________________________

(4)	Phone no., mobile no. & E-mail ID : ______________________________

  ______________________________

  ______________________________

(5)	Passport Details: 	__________________________________________

(6)	Date of birth (in dd/mm/yyyy format): _____________________________

(7)	Details of Educational/Professional Qualification (starting with the the highest degree, also mention the title of your Ph.D. Thesis, copies of certificates may be attached):

Qualification	Year	Division/
Grade	Subject(s)	

				

				
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(8)	Languages known: 	___________________________________________

(9)	Subject with area of specialization: _______________________________

(10)	Details of Professional/Teaching Experience:

Name of Institution 	Designation	Period 	Nature of duties (Teaching/ Research etc.)/Courses taught 	

				

				

				

(11)	Present designation: 	______________________________________

(12)	Present pay band:		______________________________________

(13)	Present basic pay & grade pay: ________________________________

(14)	Date of annual increment:  ____________________________________

(15)	Date of Superannuation: ______________________________________

(16)	Details of research activities and publications including supervised Ph.D. 
works, projects undertaken, published books/research papers/book chapters/ articles/ monographs etc.: (Please enclose a separate sheet indicating these details)

(17)	Details of participation in National/International Seminars/ Symposium/ 
Conference: (Please enclose separate sheets for details)

(18)	Whether empanelled with ICCR before. If so, year of empanelment.

(19)	Whether deputed abroad earlier by ICCR or by any other organization for 
academic purposes. If so, provide details in separate sheet giving details of 	year (duration, institute, etc.).
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(20)	Any other relevant information:  

Declaration:

I hereby declare that the information provided above is true to the best of my knowledge and belief. I also declare that I would be available to take ICCR’s assignment as and when a vacancy is offered to me failing which I shall have no claim and ICCR will have the right to decide whether to consider me for further vacancies or not.

Place:                                                       	Signature: _____________________

Date:                                                        	Name: ________________________