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(Full Name in Block Letter Including Surname) : Signature of The Principal

This document is an application form for a compulsory resident specialist position. It requests information such as name, registration number, contact details, date of birth, community, theory marks obtained, spouse employment details, bank account details, PAN number, and signature. The form needs to be submitted in three attested copies at the time of counseling along with photos and details of area of study and degree/diploma. It also has a section for office use only to indicate allotted posting details signed by the counseling authority.

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Santosh Babu
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287 views1 page

(Full Name in Block Letter Including Surname) : Signature of The Principal

This document is an application form for a compulsory resident specialist position. It requests information such as name, registration number, contact details, date of birth, community, theory marks obtained, spouse employment details, bank account details, PAN number, and signature. The form needs to be submitted in three attested copies at the time of counseling along with photos and details of area of study and degree/diploma. It also has a section for office use only to indicate allotted posting details signed by the counseling authority.

Uploaded by

Santosh Babu
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FORM

Please download three copies and submit the three attested copy at the time of counseling )
COMPULSORY RESIDENT SPECIALIST
Speciality: ______________________ Degree/ Diploma:______________
Area of study OU/SVU/AU
Local

:________________________________
Affix Photo

Non Local

Name of College and Place:

________________________________

1.Name of the Candidate

:____________________________

(Full Name in block letter including surname)

2.Reg.No. (Dr.NTR UHS)

:_______________________________________

3.Email-id

:_______________________________________

4.Phone / Mobile No.

:_______________________________________

5.Address for communication

:_______________________________________
_______________________________________
_______________________________________

6. Sex : Male/Female

7. Community : OC/BC/SC/ST

8. Date of Birth

:
D

9.Fathers / Husband / Wife (1) Address

:______________________________________
_______________________________________
_______________________________________

(2) Contact No :_______________


10. Theory Marks obtained in the Diploma / Degree /Super Specialty exam :_____________
11. Whether Spouse is working in Govt. service or doing PG :
12. Details of Bank Account

Yes / No

1) Name of the Bank

:______________________________________

2) Branch

:______________________________________

3) Account No

:______________________________________

4) IFSC code

:______________________________________

13. PAN No.

:______________________________________

Signature of Candidate

Signature of the Principal


(For office use only)
Allotted for posting from _________________ to _______________ in DME/APVVP/ Others ,
In _____________________________________________________College / Hospital.

Signature of Counseling Authority

for Director of Medical Education

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