N.B. PLEASE COMPLETE THIS FORM PAYING SPECIAL ATTENTION TOITEMS (b), (c) AND (d). PLEASE SUBMIT A TOTAL OF FOUR (4) PASSPORT-SIZED PHOTOGRAPHS

TRINIDAD AND TOBAGO

IMMIGRATION REGULATIONS, 1974

APPLICATION FOR A WORK PERMIT OR AN EXTENSION OF A WORK PERMIT

TO: The Permanent Secretary, Ministry of National Security

Note: Applicants wishing to employ persons are requested to submit in respect of the respective employee twelve (12) completed copies of this form to the Permanent Secretary along with the following:–(a) The official receipt of the Comptroller of Accounts evidencing payment of the fee payable on application

for the work permit;(b) three (3) photographs of the prospective employee;(c) a police certificate with respect to the previous five (5) years;(d) two (2) written character references, one (1) of which must be from the last employer; and(e) in cases of extension, proof that all income tax due, has been paid.

1. Full name: Dr. CHANDRASHEKHAR G. UNAKAL

Mrs………………………………………………………………………………………………………………..

Miss……………………………………………………………………………………………………………….

2. Date and Place of Birth: 01/01/1978

3. Present Nationality: INDIAN

4. Previous Nationality: INDIAN

5. Passport No.: J8299889 Place and date of issue…: BANGALORE, INDIA/ 19/08/2011.

6. Particulars of any change of nam.: - NIL -

7. Permanent Address…: DR. CHANDRASHEKHAR UNAKALAT; DASANURTALU: KALAGHATAGIDISTRICT: DHARWAD-580114KARNATAKA

8. Marital Status…: MARRIED

9. Full name of wife: RASHMI KUSUGAL

10. Particulars of Children: 01 (6 Month old)

Name Date ofBirth

Place ofBirth

Nationality PassportNumber

Place andDate ofIssue

Anvi Chandrashekhar Unakal

09/08/2014 DHARWAD INDIAN Applied at Bangalore, IndiaApp. Ref. No. 15-1000494089

Bangalore

11. Profession or occupation to be followed in Trinidad and Tobago: Lecturer in Microbiology, St. Augustine University.

12. State job experience, including on-the-job training

Ten Years of teaching and research experience in field of Microbiology

13. Whether accompanied by wife/husband: Yes, Rashmi Kusugal. Passport No. J7966061

14. Whether accompanied by children.: Yes, Anvi C. Unakal, Applied for Passport/ Appl. Ref. No. 15-1000494089

15. Date of arrival/intended arrival in Trinidad and Tobago (in relation to present application).: 10/April/ 2015

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16. Local residential address.: I will opt for University furnished accommodation soon I arrive at Trinidad

17. Particulars of employment during the past five (5) years:–

Employer Employer’sAddress

PositionHeld

Duration ofEmployment

Reason forTermination

University of Gondar, Ethiopia

Vice President (Academic)Post Box No. 196University of GondarEthiopia

Associate Professor in Microbiology

Feb 2013 to till date ------

University of Gondar, Ethiopia

Vice President (Academic)Post Box No. 196University of GondarEthiopia

Assistant Professor in Microbiology

November 2009 to January 2013

Promoted to Associate professor

Karnataka University, Dharwad, India

The RegistrarKarnataka University, Dharwad, India

Guest Lecturer in Microbiology

January 2005 to June 2009

Appointed to University of Gondar

18. Place/places of residence during the last ten (10) years preceding the application giving dates of such residence in each country:–

Dasanur, Taluk kalaghatagi, District Dharwad, Karnataka, Inida/ From birth till November 2009. Univeristy of Gondar, Ethiopia / From November 2009 to till date

19. Particulars of income assured while employed in Trinidad and Tobago, (state salary, commission, perquisites and other benefits):–

Basic salary of TT$259,668.00 per annum A special allowance of 6% of Basic salary A transportation allowance of TT$ 3,250.00 per month

20. SCHOOLS/UNIVERSITIES ATTENDED:Institution Dates Degree/Diplomas Dates

From To Certificates Obtained Awarded

(1) Secondary/High School: June 1999 to June 2002 BSc. June 2002

(2) University: August 2003 to May 2005 MSc. May 2005

(3) Other Courses: June 2006 to September 2009 PhD. September 2009

21. If to be self-employed give particulars of intended business on a separate sheet including financial circumstances with documentary support and business references:

………………………………………………………………………………………………………………………………..- - - - - -

………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………..

22. Has the prospective employee ever been deported or required to leave any other country?. No .

23. State offences (other than traffic offences) of which applicant has been convicted, if any, and give the date of conviction in each case.

I, Dr. Chandrashekhar G. Unakal hereby declare that the foregoing particulars are true and correct.

…………………………………………….. Signature of Employee

Date…………………………………………24. Capital formation of company including:–

(a) percentage of capital owned by Nationals of Trinidad and Tobago ………………………………………………

(b) percentage of capital owned by Non-Nationals of Trinidad and Tobago who are residents……………………...

(c) whether subsidiary or affiliate of foreign-based company, and if so, name of parent company.

………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………

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