जवाहरलाल स्नातकोत्तर आयुर्विज्ञान शिक्षा एवं अनुसंधान संस्थान
JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION & RESEARCH
(स्वास्थ्य एवं परिवार कल्याण मंत्रालय, भारत सरकार के अधीन राष्ट्रीय
महत्व का संस्थान, भारत सरकार)
(An Institution of National Importance under Ministry of Health & Family welfare, Govt. of India)
धन्वंतरि नगर, पुदुच्चेरी / Dhanvantari Nagar, Puducherry- 605 006
Phone: 0413 – 2296025 Website: www.jipmer.edu.in
APPLICATION FOR THE POST OF ASSISTANT PROFESSOR
ON CONTRACT BASIS FOR JIPMER, PUDUCHERRY
NOTE
1. TO AVOID ANY MIS-REPRESENTATION OR MIS-
INTERPRETATION OF FACTS, THE APPLICATION MUST
BE DULY TYPED / HANDWRITTEN, SUPPORTED WITH
SELF-ATTESTED COPIES OF TESTIMONIALS.
PASTE
2. BRIEF RESUME OF THE CANDIDATE TO BE SUBMITTED THE LATEST
AS PER APPLICATION FORM SELF ATTESTED
PHOTOGRAPH
HERE
DEPARTMENT /
SPECIALTY : ____________________________________________________
1. FULL NAME
:
(BLOCK LETTERS) ____________________________________________________
2. FATHER’S/HUSBAND’S
:
NAME ____________________________________________________
3. (A) MAILING ADDRESS :
____________________________________________________
____________________________________________________
____________________________________________________
PIN CODE :
______________________________
MOB. NO. : ______________________________
E-MAIL ID :
____________________________________________________
-2-
(B) PERMANENT ADDRESS :
____________________________________________________
____________________________________________________
____________________________________________________
PIN CODE :
___________________
MOB. NO. :
______________________________
[ ] [ ] [ ]
4. ______________________ ______________________ ______________________
(A) DATE OF BIRTH :
{Date} {Month} {Year}
[ ] [ ] [ ]
(B) AGE: ______________________ ______________________ ______________________
:
(AS ON 30.08.2025) {Years} {Months} {Days}
(C) SEX : Male / Female
(D) MARITAL STATUS : Married / Unmarried
5. CANDIDATE BELONGS TO
[Tick ( ) which is applicable] : UR OBC SC ST EWS
6. APPLIED CATEGORY
[Tick ( ) which is applicable] : UR OBC
7. WHETHER CANDIDATE : Yes / No
BELONGS TO PwBD
8. STATE OF DOMICILE : ___________________
9. NATIONALITY : ___________________
10. RELIGION : ___________________
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11. REGISTRATION NO.
A) WITH THE NMC/MCI : ___________________
B) STATE IN WHICH
REGISTERED :
___________________
C) VAILD UPTO : ___________________
12.
(Kindly attach self-attested copies of certificates / degrees
EDUCATIONAL QUALIFICATION :
in support of your qualifications)
(a) Under-Graduate
Examination No. of Class / University / Institution
Year of Passing
Passed attempts Division (with full address)
Matric /
S.S.L.C.
Intermediate /
HSC
M.B.B.S.
(b) Post-Graduate
Examination No. of Class / University / Institution
Year of Passing
Passed attempts Division (with full address)
M.D./ DNB
D.M./M.Ch.*
Others
(If any)
* Must indicate No. of years of the course (2yrs/3yrs/5yrs)
-4-
13. TEACHING/RESEARCH EXPERIENCE : (Please attach attested copies of experience Certificates)
After obtaining MD/DM/M.Ch/DNB/Qualification (Add additional rows, if required)
Post held Period Total period
(indicate
Pay
Permanent/ Employer’s Address
From To Yrs. Mths. Days Scale
Temporary
/Contract)
TOTAL
14. PRESENT EMPLOYMENT /
:
POST HELD _________________________________________________
COMPLETE ADDRESS OF PRESENT
:
EMPLOYER _________________________________________________
15. I HAVE ATTACHED ATTESTED COPIES OF CERTIFICATES / DOCUMENTS IN SUPPORT
OF AGE, CATEGORY, QUALIFICATION AND EXPERIENCE ETC. AS PER LIST ENCLOSED
PLACE : SIGNATURE OF THE CANDIDATE
DATE :
NOTE:
INCOMPLETE APPLICATION AND THE APPLICATION RECEIVED WITHOUT
e-RECEIPT FOR FEE PAYMENT THROUGH SBI COLLECT OF THE REQUIRED
AMOUNT WILL NOT BE ENTERTAINED.
SUBMIT ALONG WITH APPLICATION, ONE SELF-ATTESTED PHOTOCOPY OF
THE DOCUMENTS REFERRED AT ANNEXURE
DECLARATION BY THE CANDIDATE
(Post applied: ASSISTANT PROFESSOR on contract basis at JIPMER, Puducherry)
I hereby declare that the informations furnished in the application proforma are 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 false information/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 I
am not aware of any circumstance which might impair my fitness for employment under the
Government on contract basis.
PLACE :
SIGNATURE OF THE CANDIDATE
DATE :
Check List
List of enclosures to be submitted along with the application
SL. NO. PARTICULARS OF ENCLOSURES TICK ( ) IF ENCLOSED
1. Proof of age (i.e. High School/Higher Secondary
Certificate/Birth Certificate)
2. 10th & 12th Certificate
3. M.B.B.S. Certificate
4. PG Certificate(s): MD/DM/MCh/DNB
whichever applicable
5. Experience Certificate(s)
6. Registration & Additional Registration
Certificate with NMC/MCI
7. Registration renewal validity (if applicable)
8. OBC (Non-Creamy Layer) Certificate (if
applicable)
9. NoC (if applicable)
10. Brief resume of the candidate in the prescribed
format
11. Reprints of five best publications (Not more than
5 publications must be attached)
12. e-Receipt for fee payment through SBI Collect
13. Any other relevant Certificate(s)
