SHIVAJI UNIVERSITY, KOLHAPUR
DEPARTMENT OF CHEMISTRY
(DST-FIST, UGC-SAP Recognized Department)
Refresher Course in Chemistry
(under theUGC-Academic staff College,
Savitribai Phule Pune University, Pune)
 Important dates:
1. Last date of submission of application forms:
upto 30th September 2015
2. Declaration of list of selected participants: 15th October 2015
3. Duration of course: 16th November to 6th December, 2015
 Application form is available on website
http://www.ascpune.net/ascdownload.html
http://www.ascpune.net/download/ApplicationformOrientationRefresherProgramme.pdf
http://www.unishivaji.ac.in
 Application forms may be sent to : UGC-Academic Staff College,
Savitribai Phule Pune University, Pune
Or
at following address
Prof. (Dr.) Sanjay Kolekar
Co-ordinator, Refresher Course in Chemistry
Department of Chemistry
Shivaji University, Kolhapur-416004 Maharashtra
Tel: +91 231 2609163 / 9164(O)
Cell : +91 9881762426
Fax: +91 231 2692333
Email: [email protected]
[email protected]
[email protected]
UGC-ACADEMIC STAFF COLLEGE
SAVITRIBAI PHULE PUNE UNIVERSITY
PUNE – 411007
(Incomplete form will not be entertained)
For Office Use Only
The applicant attended
OP/RC as indicated below
Affix your latest
photograph
(without photograph
form will not be
entertained)
APPLICATION FORM
For participation in the UGC sponsored
REFRESHER COURSE IN
ORIENTATION PROGRAMME
Commencing from
To
(Strike out whichever is not applicable and mark to your choice)
Surname
First Name
Middle Name
1. Name of Applicant
(In Capital Letter)
2. Date of Birth
4. Category
SC
Male
3. Sex
ST
6. Knowledge of Marathi
DT/NT
OBC OPEN
READ
5. Mother-tongue
WRITE
CAN UNDERSTAND
Degree
7. Educational Qualifications
Female
B.A. B.Com B.Sc. B.Ed.
M.A. M.Com M.Sc. M.Ed.
NO
Subject
LL.B. B.Lib.
LL.M. M.Lib.
M.Phil.
Ph.D.
8. Name and Address of the College/Institution where the applicant is employed :
9. University to which the College/Institution is affiliated :
10. Address for correspondence :
PIN.
11. Designation
Phone Res/Office:
Mobile 1 :
E-mail :
Assistant Professor
Associate Professor
Professor
12. Date of Appointment as Assistant Professor
(P.T.O.
13. Date of Placement in Existing Grade pay
Regular
Confirmed
14. Nature of Appointment
15. Present Pay Scale : Rs.
16. Teaching Experience
(in years) at Senior
College/University
Regular
Probation
Adhoc
Temporary
15600-39100 (GP- 6000)
15600-39100
(GP7000)
or
or or
37400-67000 (GP- 9000)
37400-67000 (GP- 10000)
Total
Degree Classes
17. Have you attended any programme so far?
Yes
No
15600-39100 (GP- 8000)
PG Classes
If yes, indicate below:
And
Orientation
(OP)
Refresher Course / Special Summer / Winter School in the subject of
OR
18. Give dates, name(s) and address(e) of the Academic Staff College/Institute where you attend the programme(s):
1. Date
Address
To
2. Date
Address
To
To
3. Date
Address
To
4. Date
Address
19. Hostel Accommodation
Required
Not required
I hereby undertake to participate in all the academic sessions and assignment work during the course and will
abide by the rules and regulations of the Academic Staff College/University of the University Grants Commission.
Place : _____________________
Date : ______________________
Signature of the Applicant
RECOMMENDATIONS OF THE FORWARDING AUTHORITY
1. I recommend Dr./Mr./Ms…………………………..…………………………………………………………………………………..
.………………………………………………………………………………………………… for the Orientation Programme/
Refresher Course in the subject of ……………………………………….…. He/she will be relieved on time to participate in
the above Course at Academic Staff College, if selected.
2. Certified that this college is affiliated to …………………………………………… University for the last 5 years.
Place : ______________________
Date : _______________________
Signature of the Principal/
Registrar/ Head of the Institution
Office Seal