APPLICATION FORM Affix your
recent
1. Advertisement no. and Sl. No. of the Post: .......................................................... passport
size
photograph
2. Post Applied for: .........................................................Category.......................
here
3. Name (in block letter) : .........................................................................................................................
4. Father's Name : ....................................................................................................................................
5. Candidate's Category (UR/SC/ST/OBC/EWS/Physically Handicapped) : .............................................
6. Date & Place of Birth (attach proof) : ........................................................................................................
7. Nationality : ............................................................................................................................................
8. Marital Status : ........................................................................................................................................
9. Date of Marriage : ....................................................................................................................................
10. Address for Correspondence (with Phone no and Email ID) :
...................................................................................................................................................................
..................................................................................................................................................................
...................................................................................................................................................................
11. Permanent Address :
...................................................................................................................................................................
..................................................................................................................................................................
...................................................................................................................................................................
12. Adhar card No. : .........................................................................................................................................
13. Age as on 01-07-2022 : Year __________ Month__________Day_______
14. Medical Council Registration :
Degree Name of Medical Council Registration Number Date of Registration
MBBS
MD/MS
MCH/DM
15. Qualifications : (Self attested photocopies certificates & marksheets)
Exam Board/ University Year of Subject Marks Percentage Attempts
Passed Passing obtained/ (if any)
Total
Marks
16. Experience (if any):
S.No. Post Institution From To Total
Experience
1 Professor
2 Associate Professor
3 Assistant Professor
4 Tutor
5 Present work/Designation
______________________
17. Publications :
S.No. Post Research Publications
1 Professor
2 Associate Professor
3 Assistant Professor
4 Tutor
18. Any other relevant information :
Date : ...........................
Place : ........................... Name & Signature
Declaration
I Dr. ................................................................. hereby certify that the fore-going
information is correct to the best of my knowledge and belief. I have not suppressed any
material fact or factual information in the above statement. In case, I have given wrong
information or suppressed any material fact or factual information, then my service are liable
to be terminated without giving any notice or reason thereof.
I have not been indulge in any criminal activities and no judicial cases are pending with me.
Date : .............................
Place :............................. Name & Signature
