Tele : “JIPMER” Phone : 2272380-2272389

Website: www.jipmer.edu.in Fax : 0413 – 2272067,

2272735

JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION

AND RESEARCH, PUDUCHERRY-6.
(Institute of National Importance under the Ministry of Health & Family Welfare,
Government of India)

Estt. I (27)//2010. Dated:

NOTE:

1. TO AVOID ANY MIS-REPRESENTATION

OR INTERPRETATION OF FACTS, THE
APPLICATION MUST BE SENT DULY
‘TYPED’ (IN DUPLICATE), SUPPORTED
WITH ATTESTED COPIES OF
TESTIMONIALS.

2. BRIEF OF CANDIDATE FOR DIRECT

RECRUITMENT AT PAGE NO. 11 TO BE
SUBMITTED IN DUPLICATE

PASTE HERE SELF

ATTESTED
LATEST
PHOTOGRAPH

Post applied for : ________________________________________________

Speciality :
________________________________________________

1. (a) Full Name (BLOCK LETTERS):

--------------------------------------------------------------------------------
-
2. Father’s/Husband’s Name_____________________________________________

3. (a) Mailing Address: _____________________________________________

_____________________________________________

_____________________________________________

Tel. No. _______________________Pin:_____________________

Fax. No. __________________ Mobile No.____________________

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(b) Permanent Address_______________________________________________

_______________________________________________

_______________________________________________

Tel. No: _________________________Pin:___________________

Fax. No:______________________ Mobile No:________________

4. (a) Date of Birth: [ ] [ ] [ ]

-------------- -------------- ------------
{Date} {Month} {Year}

(b) Age: [ ] [ ] [ ]
-------------- -------------- ------------
{Years} {Months} {Days}

(c) Sex: Male/Female (d) Marital Status: Married/Unmarried

5. Whether belong to:

Gen. S.C S.T OBC P.H.

(Please strike out which is not applicable) (Attach attested copy of certificate on the
proforma)

6. State of Domicile :_______________________________________________

7. Nationality ___________________ Religion___________________________

8. a) Registration No. with the Medical Council:____________________________

 b) State in which registered___________________________________________

9. Educational Qualifications:
(Please attach attested copies of certificates/degrees in support of your qualifications)

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(a) Undergraduate Career

Examination Year of No. of Class/Division University/

Passed Passing attempts Institution

Matric/S.S.C.
Intermediate/
HSC

B.Sc.

M.B.B.S/B.D.S.

1st Profl.

2nd Profl.

3rd Profl.

4th Profl.

Final Profl.

(b) Postgraduate Career:

Examination Year of No. of Class/Division University/

Passed Passing attempts Institution
M.D./M.S/M.D.S.

D.M/M.Ch.

D.N.B.

M. Sc.

Ph.D.

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10. Teaching/Research Experience:

(Please attach attested copies of experience Certificates)

a) Before obtaining Postgraduate Qualification:

Post held Period Total period Pay Employer’s Address

(indicate Scale
Temporary/ From To Yrs. Mths. Days
Permanent)

(b) After obtaining Postgraduate Qualification:

Post held Period Total period Pay Employer’s Address

(indicate Scale
Temporary/ From To Yrs. Mths. Days
Permanent)
 :5:

11. Details of Prizes, Medals,

Scholarships & National /
International Awards etc.

12. Additional qualification

such as Membership of Scientific
Society etc.

13. Research Experience, if NUMBER OF PAPERS

any, together with details of Accepted
published works in indexed Published for Presented at
journals. public- conference
ation
Indexed Non
Indexed

NATIONAL

INTER-NATIONAL

14. Chapter in books/books edited :__________________________________

15. (a) Present employment/post held :__________________________________

(b) Pay Scale :_________________________________

(c) Total emoluments drawn :________________________________

 (d) Address of present employer :_________________________________

16. Are you willing to accept the

minimum initial pay offered? If not,
state what is the exact initial pay you
would accept in the prescribed scale? __________________________________

17. If Selected, what notice would

you require before joining _______________________________________

18. Have you been outside India for

Academic Purpose? If so, give
following information: _____________________________________

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Country Dates of Duration of Visit Purpose of visit

visited Visit
From To Yrs. Mths. Days

19. State the foreign languages you know:

Foreign Language Can read Can write Can speak

(i)

(ii)

(iii)

20. Give below the names/particulars of two referees from your speciality who are in a
position to testify from personal knowledge to your fitness for the post.

Note:
i. You should have worked with one of the referees for atleast two years.
 ii. They must not be related to you
iii. They must not be members of the Selection Committee of the Institute.

NAME STATUS ADDRESS

1.

2.

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21. I attach attested copies of certificates/degrees in support of age, category, qualification

and experience etc. as per list enclosed Annexure-I.

22. Self-evaluation of your work, particularly its strengths in different fields of activity
including patient-care, teaching research and administrative, related to the job, which,
in your view, entitles you to the post applied for may be given in Annexure-II.

23. Please submit along with your application, the photocopies of your publications which
you consider ‘BEST’ as under:-

i) For the post of Professor (10 copies each of 10 best publications)

ii) For the post of Asst. Professor (10 copies each of 5 best publications)

NOTE: INCOMPLETE APPLICATION AND THE APPLICATION RECEIVED

WITHOUT DEMAND DRAFT OF THE REQUIRED AMOUNT WILL

NOT BE ENTERTAINED.

Date: Signature of the candidate

Place:

DECLARATION BY THE CANDIDATE

Post applied for ___________________________________at JIPMER,

Puducherry-6. I hereby declare that the above information is true, complete and correct
to the best of my knowledge and belief. I have not suppressed any material, fact or
factual information. I understand that my candidature is liable to be rejected in the event
of any mis-statement/discrepancy in the particulars being detected and after my
appointment in such an event, my services are liable to be terminated without any notice
to me or reasons thereof I am not aware of any circumstance which might impair my
fitness for employment under the Government.

Date: Signature of the candidate

Place:

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*DECLARATION TO BE SIGNED BY OBC CANDIDATES ONLY

I ___________________________________son/daughter/wife of __________________
resident of Village/Town/City/District ________________________________________
State ___________________________Community_____________(certificate enclosed)
hereby declare that I belong to the _______________________________ community
which is recognized as a backward class by the Govt. Of India for the purpose of
reservation in services as per orders contained in Department of Personnel and Training
Office Memorandum No.36012/22/93-Estt(SCT) dated 8.9.1993. It is also declared that I
do not belong to the persons/sections(creamy layer) mentioned in Column 3 of OM
No.36012/22/93.Estt(SCT) dated 08.09.1993 and modified vide Govt. of India,
Department of Personnel and Training OM No.36033/3/2004-Estt(Res) dated
09.03.2004.

Place: (Signature of applicant)

Date: (in running handwriting)

* Note: 1. The closing date for receipt of application will be treated as the date of
reckoning for OBC status of the candidate and also, for assuming that the
candidate does not fall in the creamy layer.

Candidates already employed should get the following endorsement signed

by his/her present employer (appointing authority).

1. Certified that Dr./Shri/Smt./Kumari ___________________________________

 holds a post of _______________________________________________for the
period from ________________ to ______________________on ____________
basis in this Department/Office/Institution/Organization. I have no objection to
his/her application being considered for the post.

2. Certified that he/she submitted his/her application to the Department /Office/

Institution/Organization on ____________________________ for onward
transmission to the JIPMER, Puducherry-6.

No. _____________________________ Signature ______________________

Dated ____________________________ Designation ____________________

Office Stamp _____________________

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DETAIL OF PARENTS/FAMILY:

NAME AGE Occupation (if in Gross

service please Monthly
mentioned Income
Post/Designation &
Employer’s Name

Father

Mother

Spouse

Child

Date: Signature of Applicant

ANNEXURE-I

LIST OF ENCLOSURES: (Required under column 21 of the application)

S.No Particulars of enclosures Marked page(s)

1. Birth Certificate
2. Matriculation Certificate

3. MBBS/B.D.S./B. Sc Certificate

4. M..D/M.S/M.D.S./M.Sc Certificate

5. D.N.B./D..M/.M Ch./Ph. D certificate

6. Experience Certificate(s)

7. Community Certificate (SC,ST,OBC,PH)

8. Registration with Medical Council Certificate

9. Any other relevant certificate(s)

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ANNEXURE-II

JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION

AND RESEARCH, PUDUCHERRY-6.
(Institute of National Importance under the Ministry of Health & Family Welfare,
Government of India)

Post applied for ________________________________________________________

SELF EVALUATION
(Require under Column 22 of the application)
Date: Signature of Candidate