आई सी एम आर - राष्ट्रीय ऩोषण संस्थान

INDIAN COUNCIL OF
NIN
NATIONAL INSTITUTE
स्वास््य अनुसंधान ववभाग, स्वास््य और ऩररवार
कल्याण मंत्राऱय, भारत सरकार
ICMR – National Institute of Nutrition
MEDICAL RESEARCH OF NUTRITION Department of Health Research, Ministry of Health
and Family Welfare, Government of India

APPLICATION FORM
(Separate application for each post should be submitted as per notification)

No.Advt.No.2/Admn-EMP/2019-20 Closing Date: 25-09-2019

Note: All columns to be filled in words and not by dashes and dots. No
column should be left blank
Please read the notification thoroughly before filling the Affix latest
application form photograph
and sign on
Name of the Post applied for the same
Post Code
Category applied for

1. Applicant’s Name in full (in block Letters)

2. Father’s/Huband’s Name

3. Gender (Male/Female)

4. Marital Status (Married/Unmarried/ Widow)

5. (a) Date of birth (Date/Month/Year)

(b) Present age ( as on the last date of
________Years _________ Months ________days
receipt of application i.e., 25-09-2019)
6. Category (enclose Certificate in case of
reserved category)
Whether UR/SC/ST/OBC(Non-creamy layer)
EWS/PWD/Divyang
7. (a) Postal address (Present) including Pin
Code

(b) Permanent address including Pin Code

(c) Email ID (Mandatory)

(d) Mobile No. /Telephone No.
Contd....2/-
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 आई सी एम आर - राष्ट्रीय ऩोषण संस्थान

INDIAN COUNCIL OF
NIN
NATIONAL INSTITUTE
स्वास््य अनुसंधान ववभाग, स्वास््य और ऩररवार
कल्याण मंत्राऱय, भारत सरकार
ICMR – National Institute of Nutrition
MEDICAL RESEARCH OF NUTRITION Department of Health Research, Ministry of Health
and Family Welfare, Government of India

8 Fee Details Amount Rs.___________________

(If exempted mentioned “EXEMEPTED” with
D.D.No. ________________ Date______________
reason of exemption
Name of the Bank:__________________________
IFS Code: _________________________________

9. Educational /Technical / Professional qualifications: (Enclose a separate sheet if space is not

sufficient)
Examination passed Year of Name of the Board / Class/ Subjects studied
passing University Percentage
obtained
X/SSC

XII/Intermediate

Graduation

Post/Graduation

Other Qualifications if
any

10. Previous service details (Chronologically stating from the Present Employer) (Enclose a separate
sheet if space is not sufficient)

Employer Name Post Nature of Period Responsibility Salary (excluding Present pay/
allowance last
and Address held Employment pay drawn & Pay consolidated
From To Matrix /Scale of pay
pay

2
 आई सी एम आर - राष्ट्रीय ऩोषण संस्थान

INDIAN COUNCIL OF
NIN
NATIONAL INSTITUTE
स्वास््य अनुसंधान ववभाग, स्वास््य और ऩररवार
कल्याण मंत्राऱय, भारत सरकार
ICMR – National Institute of Nutrition
MEDICAL RESEARCH OF NUTRITION Department of Health Research, Ministry of Health
and Family Welfare, Government of India

11. Languages known (read / write / speak)

Language Read Write Speak
Write languages known at Language
column and against reading, write &
speak

12. Additional Information , if any (Enclose a separate sheet if space is not is not sufficient)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

13. Employment details (enclosed experience certificate/NOC)

References:
1. Name : 2. Name :
Occupation : Occupation :
Address : Address :
: :
: :

DECLARATION / UNDERTAKING

I affirm that the information given in this application is true and correct to the best of my
knowledge and belief and nothing has been concealed therefrom. I also fully understand that if at any
stage of recruitment/appointment it is found that any attempt has been made by me to conceal any
information/facts, my candidate will be summarily rejected and the appointment will be terminated
without assigning any notice or reasons thereof.

I have also satisfied myself that I am eligible for the post applied in all respects and fulfil all the
eligibility criteria as mentioned in the Notification. I understand that in case, at any stage of recruitment
Or after appointment, it is found that I do not fulfil the required qualification Or otherwise not
eligible, my candidature/appointment will be cancelled without assigning any reasons Or notice thereof
to me irrespective of my marks obtained in the written test/qualifying skill test.

Place: ______________________

Date : ______________________ Signature of the candidate

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 आई सी एम आर - राष्ट्रीय ऩोषण संस्थान

INDIAN COUNCIL OF
NIN
NATIONAL INSTITUTE
स्वास््य अनुसंधान ववभाग, स्वास््य और ऩररवार
कल्याण मंत्राऱय, भारत सरकार
ICMR – National Institute of Nutrition
MEDICAL RESEARCH OF NUTRITION Department of Health Research, Ministry of Health
and Family Welfare, Government of India

ENDORSEMENT BY THE PRESENT EMPLOYER / APPOINTMENT AUTHORITY

(FOR APPLYING THROUGH PROPER CHANNEL)

1. It is certified That Mr./Mrs./Miss./Dr.________________________________________________

Designation __________________________ is presently working in the temporary / permanent
capacity with effect from _______________________. This organization has no objection in his
/ her applying to the post as above.

2. It is certified that his / her Entry pay (EP) Level is ______________________________________.

He/she is drawing a basis pay of Rs. ___________________. His /her next increment is due on
_____________________.

3. It is certified that no disciplinary / vigilance case has ever been contemplated Or pending
against him / her.
4. It is certified that no minor / major penalty has been imposed on
Mr./Mrs./Miss./Dr. ___________________________________ during his / her tenure at this
Office.

Signature:________________________
Designation:______________________
Seal of the Office:_________________