BHABHA ATOMIC RESEARCH CENTRE Application No.
______
MEDICAL DIVISION
APPLICATION FOR THE POST OF
SPECIALITY
PHOTO
POST GRADUATE RESIDENT MEDICAL OFFICER
1. Name in full beginning with : Dr.(Smt./Kum)______________________________
Surname (in block letters)
__________________________________________
2. Nationality : __________________________________________
3. Marital Status : Married / Single / Widower / Widow
4. Age & Date of Birth (in Christian era) : ___________________________________________
___________________________________________
5. Address in block letters : ___________________________________________
(a) for correspondence with PIN code:
: ___________________________________________
: ___________________________________________
Telephone/Mobile No. : ___________________________________________
Email ID : ___________________________________________
(b) Permanent Address : ___________________________________________
___________________________________________
___________________________________________
6. Whether the applicants belongs : __________________________________________
To SC/ST (if yes, please state SC
or ST & Name of sub-caste) __________________________________________
7. Educational and Professional Qualification from SSC onwards:-
Sr. Examination University/Board/ Year of Subjects Class & %
No. passed Institution passing of marks
1. SSC
2. HSC
3. MBBS
4. MD/MS/DNB
5. Appeared/
Due to
appear
(P.T.O.)
- 2 -
8. Experience & Academic achievement publications and Conference attended (Particulars of
All previous and present employment are to be furnished)
Experience in concerned speciality & No. Academic achievement/publication and
of years Conference attended
9. Details of Internship – Name of Hospital: _________________________________________
Period of Internship: From_____________________ To ____________________________
Registration No. & Date: ______________________________________________________
10. Name & address of 2 persons to whom a reference can be made regarding your
Professional competence
11. Details of relatives employed in D.A.E. or its Constituent Units:-
Sr. No. Name of Relative Relationship Unit in which Post held
employed
12. Any other information you may wish to add:
12. List of attested documents attached (Put [X] in the applicable box).
a) School Leaving Certificate (for Date of Birth) [ ]
b) Mark sheets of Educational & Professional Qualification [ ]
c) Passing Certificate [ ]
d) Experience certificate [ ]
e) MMC/MNC/MPC/DCI/IPA Registration Certificate [ ]
f) SC/ST certificate [ ]
g) Physically handicap [ ]
Date:________________ Signature:________________________
