Staff Application Form

SAMARITAN
STAFF APPLICATION FORM

1.Complete all the details in CAPITAL letters. 2. Incomplete/False information or canvassing will lead to
disqualification. 3. Teaching/Oral Tests are compulsory for teachers. 4. No TA will be paid.
THE SELECTION COMMITTEE’S DECISION IS FINAL.

Profile Image*

Name in Full*

Job Applied in*

Specific Post*

Date of Birth*

Age*

Gender* Male Female

Religion*

Marital Status*

Children*

Parent's /Husband's Name*

Permanent Address*

Telephone/Mobile No.*

Email*

Language Known (Read/Write/Speak):

1.(R/W/S)*

2.(R/W/S)

3.(R/W/S)

Health Record

Health Concerns, if any

Extra-Curricular Activities

Academic Degrees

Course	Year	Institution	Board/University	Medium	Subjects	Reg/Corres	Class/%
X
XII
UG
PG
Others

Professional Degrees*

Courss	Year	Institution	Board/University	Subjects	Reg/Corres	Class/%

Are you Pursuing Higher Education/Research?*

Have you been debarred or disqualified by any institution for any civil/criminal case?*

Can you produce the conduct/relieving orders of previous employer?*

Do you agree to stay inside the campus?*

Yes No

What is your expected salary?*

Last drawn salary*

Are you willing to abide by the rules and regulations of the institution? *

Probable Date of Joining, if selected *

Relevant Work Experience

Total Number of Years

Name & Location of the Institution	Designation	No. of Years	Period		Responsibilities	Salary	Reasons for Leaving/%
Name & Location of the Institution	Designation	No. of Years	From	To	Responsibilities	Salary	Reasons for Leaving/%

Additional Experience, if any

Personal Strengths

Personal Weaknesses

Personal/Professional Achievements

Personal/Professional Goals

Your Personal Views on Discipline, Teamwork, Character & Mentoring

Contact Information of two individuals not related to you for personal reference and verification

Name

Designation

Address

Email/Phone

I, hereby, declare that the above information is true and correct to my knowledge. If I am selected, the offer of employment will be based on the truthfulness of the statements made herein. If any information is found to be false and/or incorrect during my tenure, my appointment can be summarily terminated without due notice. I am prepared to abide by the decision of the Selection Committee and the Rules and Regulations of the Samaritan Institutions

Date

Place *

Signature of the Candidate