UNIVERSITY COLLEGE OF MEDICAL SCIENCES
(UNIVERSITY OF DELHI)
DILSHAD GARDEN, DELHI-11O 095.
(Application Form for Academic Posts)
POST APPLIED FOR ________________________________________________
Paste passport
size photograph
be affixed here
DEPARTMENT _____________________________________________________
Advertisement No MC/Estab/2/11/____________date: _______________
Note:1.
2.
3.
4.
5.
Photocopies of Certificates, degrees, proof of age and mark-sheets etc. should be attached with the application
(attested by applicant himself and originals must be produced at the time of joining, if selected)
Except where otherwise indicated, applicants appearing for interview shall do so at their own expense.
Applicants who are in employment should send their applications through their employer.
The Selecting authority may consider the name of any person for appointment, though he may not have
applied.
Separate application is required for each post applied for.
1. (i)
Name(
in
block
___________________________________________________________________
(ii)
Father's/Husband's
_______________________________________________________________
2. Date of birth
_______________
_____________
Age/as
on
(date)
letters)
Name
_____________
:
:
Years
______ Months
3. Nationality _______________Sex __________________ Married I Unmarried _______________________
4. (a) Post held, if any, at the time of sending the :
______________________________________________
application with date of appointment (state
whether permanent, on probation or temporary)
___________________________________________
(b) Name of Employing Authority :
____________________________________________________________
5. (a) Present basic monthly pay and allowances (state separately)
Pay Band
: Rs.__________________
Grade Pay
: Rs.__________________
Allowance
1. N.P.A.
: Rs.__________________
2. Traveling
: Rs.__________________
3. House Rent
: Rs.__________________
4. Any other allowance
: Rs.__________________
Total emoluments
: Rs.__________________
(b) Date of next increment:
___________________________________________________________________
(c) Age of retirement in the present post:
______________________________________________________
6. Minimum basic pay acceptable Rs. _____________________________ per month.
7. Do you belong to Scheduled Caste / Scheduled Tribe / OBC/ PWD?
If
yes,
please
attach
certificate
in
support
____________________________________
8. Address at which a reply to this application,
If any, may be sent (IN BLOCK LETTERS)
___________________________________________
Yes I No
thereof
positive.
Permanent Address
(IN BLOCK LETTERS)
________________________________________
___________________________________________
________________________________________
___________________________________________
________________________________________
PIN CODE NO. : _______________________________
PIN CODE NO.: ________________________
Telephone No. (if any) _________________________
Telephone
No.
(if
any)
__________________
Mobile No. : ___________________________________
Mobile No._____________________________
9. Whether the candidate is receiving any pensionary benefits. If so., 'the amount of pension
must be indicated
________________________________________________________________________________
10. Academic Qualifications: (Examinations passed from Matriculation / Higher Secondary
onwards to Doctorate/Research degrees).
Examination
Name of the
University Board
Year of
Passin
g
Attempts
in which
passed
Max.
Marks
Marks
Obtained
Percentage
of marks
obtained
Hons
Distinction
(Position)
Hr. Sec. or
10 + 2
Pre-Med /
M. Sc. / B.Sc.
M.B.B.S. 1st
Prof.
2nd Prof.
3rd Prof./
Final
* 4th / Final
Total Marks
of All
Professionals
Post
Graduate
(M.D./M.S.)
PG. Diploma
Degree
M.Sc./D.Sc.
Ph.D.
Total
Any other
Exam.
11. Academic distinction (e.g. any Prize, Medals, Award etc.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
* Wherever applicable.
Note:
1. Fill each column, where grading instead of marks is awarded, specify the numerical range to
each grade.
2. Weightage will not be possible where the information is found incomplete
3. For M.Sc. M.B.B.S. give percentage of marks. Total marks secured in all professional
examinations x 100 divided by total (Maximum) marks allotted for all professional
examinations.
12. Experience (i) Professional including House Job (ii) Teaching I Research Experience.
Name of the
Institution
Designation
with pay
scale
Nature of post:
Permanent/
Temporary
Class taught
Types of Duties
Period
From
13.
Administrative
experience.
____________________________________________________________
Total
Experience
to
if
any.
14. PUBLICATIONS:
Enclose a list of work which is Published or accepted for publication 1, 2
(a) Journals Total :(i)
Indexed Total (ii)
Non-indexed 1. Main Journal of applicant's
Speciality / Society of India Total 2. Others Total (b) Books :
Name of the book
Number of Chapters
Written by the applicant
Edited by
Publisher
(c) Reports: WHO UNICEF or other (specify or enclose list) Total (d) Abstracts: (Enclose list) Total 1.
2.
3.
As Proof of Work, enclose reprints of copy of the 1st page of the published work or letter of
acceptance.
No. credit will be given for published work unless it is supported by documentary evidence.
Indexed: Articles indexed in the Cumulated Index Medicus.
Note:a) Articles should be listed as per pattern used in Cumulated index Medicus.
b) No credit will be given if list is incomplete.
15. Participation in scientific meeting (enclose list)
(a) National or International conferences attended and:(i) Papers presented by you at National and international conferences:
(ii) Papers presented by others in which you are a co-author:
(iii) Invited lectures / orations given by you:
(iv) CME / Seminars / Workshop attended:
(b) Regional Conferences attended and:(i) Paper presented by you at regional conf:
(ii) Papers presented by others in which you a co-author:
(iii) Invitation lecture/orations given by you at regional conf.:
(iv) CME / Senior / Workshop attended:
16. Name and address of two referees with whom the candidate has worked earlier.
1) ________________________________________
2) ___________________________________________
_________________________________________
____________________________________________
17. Membership of National/International Scientific Bodies. ______________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
18. Extra
curricular
activities,
cultural
or
other
activities
is
interested
_________________________________________
e.g.
sports
etc.)
in
which
the
applicant
___________________________________________
and
distinction,
if
any,
obtained
in
the
same.
for
which
_________________________________________________
19.
Name
of
post
with
particulars
______________________________________________________
the
applicant
may
have
already
applied
______________________________________________________
and
which
have
not
yet
been
disposed
of.
_____________________________________________________
20. In case of selection, please state the period you would take to join
____________________________
Signature of Applicant
DECLARATION:
I declare that all the statements made in this application are true to the best of my
knowledge and belief.
Dated : ____________
Applicant
Signature of
21. Forwarded with the remarks that the facts stated in the above application have been verified
and found correct and this institution/Organization has no objection to the candidature of the
applicant being considered for the post applied for
Signature (Head of the Institution/Organization)
Designation: ____________________________________________
Pin Code No.: ___________________________________________
Telephone No: __________________________________________
Dated : ____________
Fax No: _________________________________________________
