Application Reference No.

Form : E ( Faculty / CAS / 2010/ L 10-11, 11- 12, 12-13A & 13A to 14)

Government of Karnataka
DEPARTMENT OF COLLEGIATE EDUCATION

Application form for promotion under Career Advancement Scheme (CAS) for teachers in all
Government First Grade Colleges (As per UGC 2010 regulations and subsequent amendments)

For Promotion:
I. Assistant Professor (Academic Level 10) (Stage 1) to Assistant Professor (Senior Scale/Academic
Level 11) (Stage 2)
II. Assistant Professor (Senior Scale / Academic Level 11) (Stage 2) to Assistant Professor (Selection
Grade / Academic Level 12) (Stage 3)
III. Assistant Professor (Selection Grade / Academic Level 12) (Stage 3) to Associate Professor (Academic
Level 13A) (Stage 4)
IV. Associate professor (Academic level 13A) to Professor (Academic level 14)

Application for promotion from Level to Level

Name
Paste Self-
attested
Recent
Passport
Designation

College

Department / Subject :

Notification Reference No. Date:

Period of Assessment for promotion : From IO

1
 PART — A

GENERAL INFORMATION AND ACADEMIC BACKGROUND

1. Name (in Block Letters)

2. Current Designation

3. Date of Birth and Age

4. Gender

5. Nationality
Indicate Whether Belongs to
6. (SC/ST/OBC/General/Minority/Differently
Abled)
Current Pay Scale & Grade Pay
Date of Appointment
Date of Declaration of Probation

10. Position, Stage and Grade Pay applied for

11. Date of Last Promotion, if any

12. Date of Eligibility for Promotion

13. Address for correspondence (with Pin Code)

14. Permanent Address (with Pin Code)

15. Mobile Telephone Number

16. Landline Telephone Number (with code)

17. E-Mail ID
Non-Qualifying Period of Service,
18. unauthorized absence / LWA / Department
enquiry / Disciplinary action, etc., if any

2
19. Academic Qualifications (Graduation onwards):

Name of the % Marks Division /

Year of
Qualifications Board / Obtained / Class / subject
University Passing CGPA Grade Grade
Graduate Degree (UG) Post Graduate Degree (PG)

Integrated IMA/IMSc/ IMS

(UG-PG)
Others (specify if any)

20. Eligibility Qualifications :

(a) Research Degree(s) :

Discipline /
Title of the
Subject (As per Date of Award
Degree Thesis / University
UGC — with Reg. No.
Dissertation
Regulations)
M. Phil. Ph.D./D.Phil. D.Sc./ D.Litt
Other qualifications (if any)

(a) Minimum Eligibility:

Discipline /
Subject (As per Date of
Name of Agency
UGC — Qualification
Regulations)
NET
SLET / SET

21. Previous Experience : (GFGCs)

Date of Salary with grade pay / level

Reasons for Leaving
Name of the College
Joining Leaving

3
22. Teaching Experience:

PG UG Classes Total
Classes (in (in Years) (in years)
Years)

23. Fields of Specialization in the Subject/Discipline

a)

24. Details of Orientation / Refresher / Research Methodology / Training Program/Summer and

winter School / Workshops/ QIP/ FIP /FDP etc Course attended: (Attach certificates)
(organized by Human Resource Development Center / UGC Academic staff college)

Sr. Duration Name of the Institution

No Name of the course Place No. of where program is
From to Days
conducted
01

25. Whether service relaxation is eligible for possessing Ph.D / M.Phil Yes / No

4
 PART-B

CATEGORY II: PROFESSIONAL DEVELOPMENT, CO-CURRICULAR AND

EXTENSION ACTIVITIES*

ACTUAL SELF VERIFIED

ACA
ACTUAL SCORE:
DEMI PnA API
SR. H0Ms
C ISAL SCORE
NATURE OF ACTIVITY SPENT ACTUM
No. Hons API BY
PER
YEA SCORE COMMITT
YEAR SPENT
R EE
PER YEAR ( .
- 10
15)

a Student related co-curricular, extension and

field based activities

B Contribution to corporate life and

management of the department and
institution through participation in
academic and administrative committees
and responsibilities.

Professional Development activities

* Should be claimed by the applicant with supporting documents.

Summary of Total API Score obtained for Category II (a+b+c)

Yes API Score Total (API)
(b and c)

a API Score b API Score c API Score API Score

By By By Claimed By
Claimed Claimed Claimed
Committee Committee Committee Committee

Points after
IQAC
Assessment
Based on
Documentary
Evidence
Provided

5
CATEGORY-III: RESEARCH AND ACADEMIC CONTRIBUTIONS

(A) RESEARCH PAPERS PUBLISHED IN:

A.1 Research Publications (Papers / Articles in Refereed Journals as notified by UGC)

SR. TITLE NAME OF YEAR/ Impact TYPE OF SELF SCORE BY
NO. JOURNAL ISBN/ Factor AUTHORSHIP* APPRAISAL COMMITTEE
(SR. NO./ V0L/NO/ St o
p
PAGE NO. PAGE
OF UGC NOS
LIST)

A.2 Research Publications (Papers / Articles in Reputed Journals as notified by UGC)

SR. TITLE NAME OF YEAR/ Impact TYPE OF SELF SCORE BY
NO. JOURNAL ISBN/ Factor AUTHORSHIP* APPRAISAL COMMITTEE
(SR. NO./ v0L/NO/ St o
p
PAGE NO. PAGE
OF UGC NOS
LIST)

* First & Principal Author/Corresponding Author/ Supervisor/Mentor/Other Author.

Copy of a Page(s) indicating Impact Factor and ISBN/ISSN No. in addition to above should be submitted as
Enclosure, to justify the claim.

(B) PUBLICATIONS OTHER THAN JOURNAL ARTICLES (BOOKS, CHAPTERS IN

BOOKS)
B.1 Details of Text / Reference Books, published by International Publishers, with ISBN/ISSN number
as approved by the University and posted on its website.

Sr. Title of the Author Co- Name of the ISBN / SELF SCORE BY
No. Book Author(s) Publisher, ISSN APPRAISAL COMMITTEE
Month, Year sCoRE

Note : Attach front, index and back pages justifying the claim showing the ISBN/ISSN No.

B.2 Details of Texts/References, Books, published National level publishers, with ISBN/ISSN number or
State Central Govt. Publications approved by the University an posted on its website.

Sr. Title of the Book Author Co- Name of the ISBN / SELF SCORE BY
No. Author(s) Publisher, ISSN APPRAISAL COMMITTEE
Month, Year sCoRE

Note : Attach front, index and back pages justifying the claim showing the ISBN/ISSN No.

6
B.3 Details of Subject Books, published by other local publishers, with ISBN/ISSN number as
approved by the University and posted on its website.

Sr. Title of the Book Author Co- Name of the ISBN / SELF SCORE BY
No. Author(s) Publisher, ISSN APPRAISAL COMMITTEE
Month, Year sCoRE

Note : Attach front, index and back pages justifying the claim showing the ISBN/ISSN No.

B. 4 Details of Chapters in Books, published by National and International level publishers, with
ISBN/ISSN number as approved by the University and posted on its website.

Sr. Title of Name Chapter Author / Name of ISBN SELF SCORE BY

No. the Book of the contributed Co- the / ISSN APPRAISAL COMMITTEE
Editor Author(s) Publisher sCoRE

Note : Attach front, index and back pages justifying the claim showing the ISBN/ISSN No.
(C) RESEARCH PROJECTS (RELEVANT DOCUMENTS SUPPORTING CLAIMS SHOULD BE
ENCLOSED)
C.1 Sponsored Projects (As Principal Investigator/ Co-Investigator/Project Coordinator)

Sr. Title and Funding

N Grant Duration Project sELF SCORE BY
No. Nature of the Agency ames
Status ArPRAISAL COMMITTEE
of PI Sanctioned
Project From To Completed sConE
and
(Major/Minor) / On-
co-PI
going

C.2 Consultancy Projects (As Principal Investigator/Co-Investigator/Project Coordinator)

Sr. Title and Agency Grant Duration Project sELF SCORE BY

No. Nature of the to it is Component Status ArPRAISAL COMMITTEE
Project offered Completed SCoRE
From To
/ On- going

C.3 Research Projects Outcome / Outputs

Sr. Details of Patent / Technology Year Major Policy SELF SCORE BY

No. Project transfer / Product / document APPRAISAL COMMITTEE
Process prepared scoRE

7
(D) RESEARCH GUIDANCE (RELEVANT DOCUMENTS SUPPORTING CLAIMS SHOULD BE
ENCLOSED)

D.1 Details of M. Phil Awarded*

Sr. Name of the Title of the University Month SELF SCOREBY

No. Scholar Dissertation/Thesis and APPRAISAL COMMITTEE
Year SCoRE

* Submit M.Phil. Notification

D.2 Details of Ph.D. awarded / Thesis submitted*

Sr. Name of Title of the Awarded / University Month sELF SCORE BY

No. the Thesis Thesis and Year ArPRAISAL COMMITTEE
Scholar submitted scoRE

* Submit Ph.D Notification/Certificate of Submission

(E) FELLOWSHIPS, AWARDS AND INVITED LECTURES DELIVERED IN CONFERENCES /
SEMINARS
E.1 Details of Fellowships / Awards (claims should be supported by relevant documents)

Sr. Name ofthe Awarding International / Date sELF SCORE BY

No. Fellowship/ Institute/ National / State / Awarded APPRAISAL COMMITTEE
Award Organization University level sConE

E.2 Details of Invited lectures / papers presented in conference/seminars/workshops (claims

should be supported by relevant documents)
Sr. Title Name of Organizer/ Duration International SELF SCORE BY
/ National /
No. the Event Institute State / APPRAISAL COMMITTEE
University sCow
level

The score under this sub-category shall be restricted to 20% of the minimum fixed for Category III for any
assessment period

8
Summary of API Score under Category E

API Score API Score After Capping REMARKS BY IQAC

9
(F) DEVELOPMENT OF E-LEARNING DELIVERY PROCESS/MATERIAL DETAILS
SELF SCORE BY
Development of e-learning delivery 10 per APPRAISAL COMMITTEE
(F)
process/material* module score

* Should be claimed by the applicant with supporting documents.

Claim by applicant

Summary of Total API Score obtained for Category III (A+B+C+D+E+F)

Assessment Period from tO

Year API Score Total

Entire Assessment Period A B C D E F | API Score
from to
Total API Score

For Committee Use Only

Summary of Total API Score obtained for Category III (A+B+C+D+E+F)

Assessment Period from tO

Year API Score Total

Entire Assessment Period A B C D E F | API Score
from to
Total API Score

Summary of Total API Score (Category II + Category III)

Category Criteria Total-API Score for Committee
Assessment Period
II Professional Development, Co- Curricular
And Extension Activities
III | Research And Academic Contributions
II + III | As stated above against II & III

I hereby declare that the information / documents provided by me are correct to the best of
my knowledge and belief and verifiable, and I have carefully read the relevant provisions
relating to promotion under Career Advancement Scheme (CAS) contained in UGC
Regulations, 2018 as amended from time to time.

Place Signature :
Date Name and Designation:

1
 Verified by Screening cum Evaluation Committee

Name Signature

College Principal

Head of the Department

Subject expert — 1

Subject expert — 2

Place

Date