oferta srghtgnr Pers TET All India Institute of Medical Sciences, Gorakhpur ere eee ae eT THT A EIT PHT STF (an autonomats organization under the Minty of Heath & arly Welfare Goat of i) APPLICATION FORM TO AVOID ANY MIS-REPRESENTATION OR INTERPRETATION OF FACTS, THE APPLICATION PASTE HERE MUST BE SENT DULY ‘TYPED"IN TIMES NEW LATEST ROMAN FONT, SIZE 11 PREFERABLY, SUPPORTED SELF ATTESTED. WITH ATTESTED COPIES OF TESTIMONIALS. PHOTOGRAPH 1 to be submitted Application for the Post of: at ALIMS, Gorakhpur DISCIPLINE: 1. Full Name (BLOCK LETTERS): 2. Father’s/Husband’s Name: (a) Mailing Address: — Pin Fax.No__ Te. No, Aadhar No Mobile No. E-mail ID: Page 1 of 12ART UT A SMTP TT PUTT, TTT All India Institute of Medical Sciences, Gorakhpur y ere eae eT ea MT THT A EIT PTD) yy (An autonomous organization under the Ministry of Health & Fanny Wellare, Govt, of nda) (b) Permanent Address: Pin: Tele, No. Mobile No: 4. (a) Date of Bi l rr 1 l 1 (b) Age: (as on 02.05.2022) [ 1 [ 1 [ 1 £Years} {Months} {Days} (©) Sex: Male/Female (@) Marital Status: Married/Unmarried 5S. Whether belong to: ur | |sc | |st] lonc |] |ews Whether belong to PwD: Yes |or (Please strike out which is not applicable) (Attach attested copy of certificate on the proforma) 6. Percentage of disability (If Applicable): 7. State of Domicile: 8. Nationality Religion, 9. a) Registration No. with the Medical Council: b) State in which registered 10, Educational Quali Page 2 of 12A oferta srghtgnr Pers TET All India Institute of Medical Sciences, Gorakhpur er ae eT ea eT THT PM EIT PHT (an autonomous organization under the Ministry of Health & Family Welfare, Govt, of nda) (Please attach attested copies of certificates/degrees in support of your qualifications) ind meres Examination Passed Year of Passing No. of attempts Class/Division University/ Institution Matrie/S.8.C, Intermediate HSC BSc MBBS (b) Postgraduate onwards Career: Year of Passing No. of Attempts Class/Division University/ Institution MD/MS MSc DM/MCh.* DNB. PhD. * Must indicate No. of years of the course (2yrs/3yrs/Syrs) and name of the Institute with full address 11, Teaching/Research Experience: (Please attach self attested copies of experience Certificates) Page 3 of 12+4 oferta srghtgnr Pers TET All India Institute of Medical Sciences, Gorakhpur er ae eT ea eT THT PM EIT PHT y (an autonomous organization under the Ministry of Health & Family Welfare, Govt, of nda) a) Before obtaining Postgraduate! Super Specialty/Ph.D. Qualification: Post held Fone [period | Tata period bs SNe Teper’ EE, | Employers Asdres Permanent) | From |To | Years | Months Days Toa (Aer bsning Fosgate SpeiyPhD. Quaision Poa had] period Toalperiog | sr.No. | Emplyer's Address Temporary : sie 7 Temporary’ rom | to | Yeas] Months Day Total Page 4 of 12oferta srghtgnr Pers TET All India Institute of Medical Sciences, Gorakhpur er ae eT ea eT THT PM EIT PHT SF (an autonomats organization under the Minty of Heath & Farly Welfare, Gort of i) 12, PRIZES, MEDALS, SCHOLARSHIPS ETC. AWARDED (mention only those related to the profession of the award. No. Description 13, MAJOR INTERESTS/HOBBIEVEXTRA-CURRICULAR ACTIVITIES. 14, MEMBERSHIP OF PROFESSIONAL SOCIETIES/BODIES/ASSOCIATIONS ETC. Status whether fellow, member or associate member etc. name of the society, body or association ete. and date of enrolment. 8. STATUS. NAME, DATE OF No. MEMBERSIIP Page 5 of 12oferta srghtgnr Pers TET All India Institute of Medical Sciences, Gorakhpur er ae eT ea eT THT PM EIT PHT (an autonomous organization under the Ministry of Health & Family Welfare, Govt, of nda) = 15, Research Experience, if any, together with details of published works in indexed journals. NUMBER OF PAPERS Published Pabmed Non- Pubmed a) Please provide a list of all your scientific publications in chronological order providing details of articles including whether Original article/review/case report, indexed / non-indexed, impact factor and number of citations for the articles (Best five to be written here and the rest to be attached as Annexure in the given formar): 5 Tmpact | Citations Sr Particulars of Article in Vancouver style No, i Factor 1 3 4 5 16. Chapter in books/books edited 17. (a) Present employment/post held (b) Pay Scale (©) Total emoluments drawn (@) Complete Address of present Employer. Page 6 of 12ofeeunrdasngrgnr ter Reg All India Institute of Medical Sciences, Gorakhpur care ear eT a ER TT PT) (An autonomous organization under the Ministry of Health & Family Welfare, Govt, of nda) 18, Date of Retirement and the last Institution served (Documentary Proof to be submitted) 19, Have you been outside India for Academic Purpose? Ifo, give following inform: Dates of Visit Country visited Purpose of vi From | To | Years) Months.| Days 20. State the languages you know: —] Language [Foreign No| “Language @ Can read | Can write] Can speak Gi) (ii 21. Give below the full details of 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: You should have worked with one ofthe referees fora least two year. ii, They must not be related to you NAME Designation Tstitaion ‘ADDRESS Mobile Email Page 7 of 12ART UT A SMTP TT PUTT, TTT All India Institute of Medical Sciences, Gorakhpur i y ere eae eT ea MT THT A EIT PTD) yy (An autonomous organization under the Ministry of Health & Fanny Wellare, Govt, of nda) 22, Attach self attested copies of certificates/degrees in support of age, category, qualification and experience ete. as per list enclosed. 23, 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 thepost applied for may be given in the proforma attached. Date: Signature of the candidate Place: ‘NOTE: 1, INCOMPLETE APPLICATION AND THE APPLICATION RE WITHOUT PAYMI OF THE REQUIRED Fi WILL NOT BE ENTERTAINED. 2. SUBMIT ALONG WITH APPLICATION, ONE ATTESTED PHOTOCOPIES OF DOCUMENT REFERRED AS ANNEXURES ALONG WITH THE CASTE CERTIFICATE AND NOC IF APPLICABLE. DECLARATION BY THE CANDIDATE (Post applied for at AIMS, Gorakhpur). 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 Iam not aware of any circumstance which might impair my fitness for employment under the Government on regular basis. Date: Signature of the candidate Place: Page 8 of 12oferta srghegnr Ce TET All India Institute of Medical Sciences, Gorakhpur er eee ea eT TE HT A EIT PT) (an autonomous organization under the Ministry of Health & Fanny Wellare, Govt, of nda) LIST OF ENCLOSURES: AL Post applied for SELF EVALUATION (not more than 150 words) (Require under Column 24 of the application) Date: Page 9 of 12 Sr.No, Particulars of enclosures Marked page(s) 1. | Birth Certificate 2. | Matriculation Certificate 3. | MBBS /M.Se Certificate 4. | MDIMS/ D.N.B/Ph.D Centiticate 5, | MIM Ch, certificate 6, | Experience Cenificate(s) 1 Community Certificate (SC,ST / OBC (Non- Creamy| Layer) 8. | Registration & Additional Registration with Medical Council Certificate 9 | Disability Certificate 10 | Any other relevant certificate(s) INDIA INSTITUTE OF MEDICAL SCIENCES (AIMS), GORAKHPUR Signature of Candidateofeaurdtrsrghign Gert meagR All India Institute of Medical Sciences, Gorakhpur aT eae te Rar are saree Tea TR GT wae aT PTA) (An autonomous organization under the Ministry of Health & Family Welfare, Govt. of Ini) *DECLARATION TO BE SIGNED BY OBC CANDIDATI ONL L sonidaughteriwife of resident of Village/Town/City/Distriet State Community, (certificate enclosed) hereby declare that 1 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-Esti(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: The closing date for receipt of application will be treated as the date of reckoning the OBC status of the candidate and also, for assuming that the candidate does not fall in the creamy layer. Page 10 of 12SRT TRA STARS AT PRU, TAT All India Institute of Medical Sciences, Gorakhpur eae ee ree ae rR eM RT Rae aT FTE) 1omous organization under the Ministry of Health & Family Welfare, Govt, of Ini) (an aut FORMAT OF POWER POINT PRE! Name Post Applied for & Discipline DOB & Age as on Crucial date Category Educational Qualification Teaching Experience Present Place of Work Page 11 of 12Sree MEU, TAT All India Institute of Medical Sciences, Gorakhpur eae ee ree ae eR EME RT Rae TT TE) {An autonomous organization under the Ministy of Health &t Family Welfare, Got of Inia) Best Five Publications Page 12 of 12