King Institute of Preventive Medicine & Research
Department of Virology, Guindy, Chennai – 600 032
APPLICATION FORM FOR TEMPORARY POSITIONS IN PROJECT
ON CONTRACT BASIS
(All columns are to be compulsorily filled in neatly in capital letters or printed on A-4 size paper)
Application for the position of _______________________________________________________
_________________________________________________________________________________
1. Name of the Applicant: _____________________________________________
2. Date of Birth & Age: _____________________________________________
3. Male/Female: _____________ 4. Nationality _________________________ Affix duly signed
Passport size
5. Father’s/Husband’s Name: ______________________________________ Photograph
6. A. Postal address for communication: ________________________________
________________________________
________________________________
B. Permanent Address: ________________________________
________________________________
7. A. Telephone No. & Mobile No. ________________________________
B. E-mail: ________________________________
8. Whether belongs to SC/ST/BC/MBC/DNC/
(Specify and enclose valid certificate) ________________________________
9. Have you ever been convicted by a
court of law or is there any criminal case/
disciplinary action/ vigilance enquiry
pending against you? If so specify ________________________________
10. Educational Qualifications (Attach attested copies of certificates/mark sheets, etc.)
Examinations Division with %
Subject Year of Passing Board/University
Passed of Marks
10th
12th
Bachelor's
Master's
Ph.D.
Post-doctoral
Any other
(specify)
11. Details of employment/ fellowship ( if any) in reverse chronological order (attach separate
sheet, if necessary)
Department/ Permanent/ Period of employment Scale Gross
Post Held Institute/ Temporary/
From To of pay Amount
company Contract
12. Any other relevant information: _________________________________________________
13. Details of Enclosures:
(Self-attested copies of certificates in support of Age, Educational Qualifications and First
Page of Research Publications/ Patents and work Experience as well as a detailed
BIODATA must be enclosed with this completed application)
The completely filled up application forms should be submitted to Administrative Officer,
King Institute of Preventive Medicine and Research, Guindy, Chennai 600 032.
Tamilnadu. Kindly mention the position applied for by the candidate on the envelope without
fail. If the shortlisted candidates (based upon eligibility for each post) exceed twenty in
number, then entrance examinations will be conducted for further screening and selection.
Intimation regarding the shortlisted candidates for interview will be communicated to
candidates through e mail.
Declaration
I hereby declare that I have carefully read and fully understood all the instructions and details pertaining
to the post being applied by me and all statements made and information furnished in this application
are true and complete to the best of my knowledge and belief. I also declare that I have not concealed
any material information which may debar my candidature for the post applied for. In the event of
suppression or distortion of any fact including category or educational qualification, etc. made in my
application form, I understand that I will be denied any employment in the Institute and if already
employed in any position and my services will be terminated forthwith.
Place : ______________________
Signature of the candidate
Date: ______________________
