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APPLICATION FORM
ICMR-REGIONAL MEDICAL RESEARCH CENTRE
BRD Medical College Campus, Gorakhpur, Uttar Pradesh- 273013
(Under Indian Council of Medical Research (ICMR), Govt. of India)
Application for the Post of- S.No- _________________
Category:
SC ST OBC GEN EWS EXM
1. Name of the Applicant (in CAPITAL words) :
2. Sex : Male Female Others
3. Marital Status : Married Unmarried Divorced/ Widow
4. Father's Name :
5. Name of the Spouse :
6. Date of Birth :
7. Age as on 10.03.2023 : Days Months Years
8. Address for :
Communications
:
Mobile No. :
Email:
9. Permanent Address :
: PIN
Telephone No.
Mobile No. :
10. Nationality :
11. Educational Qualification: (Enclose attested photocopies of degree/diploma certificates & mark
sheets)
%/ Month &
Examination Subjects Board/ Council/University Division Year of
Passing
Xth
(HSC)
XIIth
(HSSC)
Diploma (please mention
duration one year/two years)
Degree
Post Graduation
Others (M.Phil/Ph.D)
12. Current Activities:
13. Experience: (Enclose copies of Work Experience Certificates)
Status of Name of Whether Period Scale of
Name of the Organization the Post permanent Nature of
Pay &
Organization/
(Central/State/ held /contractual Gross Work
Institution where From To
Autonomous/ Pay
worked and Place
PSU) Drawn
(Use separate sheet if space is inadequate)
14. Knowledge of computer applications, if any, please attach certificate/diploma/degree:
15. Details of publications with impact factor, if any:
16. Name and address of two referees well known with the applicant's work:
Name Occupation or Position Address with telephone No. & e-mail
1.
2.
17. Any other information you wish to add :
18. Check List : ( Please tick in the box given below as proof of enclosures. )
All Certificates must be attested and be attached in the following order :
(i) Certificate in support of age (High School Certificate) ............................ ......................
(ii) Degree/Diploma …………..…...............................................….. ……………..
(iii) Experience Certificate .......................................................................… …………...
(iv) Caste certificate (If any)……………………………………………… ……… …………
(v) Documents relating to retrenched Govt. Employees/Departmental ………… ….
(Including Projects)
DECLARATION
I, declare that I have read the
advertisement carefully and the information furnished above is true and correct to the best of my
knowledge and belief and no related information has been concealed. I am aware that if any of the
above statements are found to be incorrect or false or any material information or particulars of
relevance have been misstated, suppressed or omitted, I am liable to be disqualified for appointment
and if appointed, my appointment will be liable to be terminated.”
Place: ..................................
Date: .................................... (Signature of the applicant)
Full Name:
