a Dr. NTR UNIVERSITY OF HEALTH SCIENCES, A.P, VIJAYAWADA-8 f& FORM FOR TEACHER DATABASE, 20 _ (NOTE : READ INSTRUCTIONS OVERLEAF CAREFULLY BEFORE FILLING THIS FORM) Form No. 1. Distt Code 2. College Code TEACHER ICR SL. No, "3. Name of the Gollege 44, Namo of the Teacher { Write CAPITAL Letters without touching edges of boxes ] (As in P.G,Degree Certificate ) Give one space after sumame. 5, Father's Name [ Write CAPITAL Letters without touching edges of boxes. Give one space aftor surname. J 8. Sex: 7, Dateof inh 8, Designation 9. PG Qualification 10. Year of PG Complain: >> ow. YY Ty 1. Reg No ofthe State Counc: 12, Teaching Experience: [Link] Pay: [Link] ‘18. PANard Nav 16 Emai Ib (vo In Catal Lote) 17 Residence Land Line Phone Number with STD Code. Wi ibs Promo Fiber Si Code Phone he 10. Residence Address Name: Boerne 20. Photo: Seat: Past cont black & White Passport Photograph with white Background kana Mat Please do not staple or pin ‘the photograph. area Please do not sign on the ahotogteah TomniGiy: PIN: | 21, Signature of the Collage Principal Within the box glven above 22, Signature of the candidate ‘within the box given aboveDr. NT R UNIVERSITY OF HEALTH SCIENCES, A.P, VISAYAWADA-8 INSTRUCTIONS AND EXAMPLES TO FILL THE FORM + 2 The application form for computerization purpose should be handled carefully. It should not be mutilated or folded. Mutilated or folded forms will not be accepted. Applications should be filled properly and legibly by the Teacher in his/her own handwriting with Blue or Black Ink ball pen, in CAPITAL LETTERS only. #% Please do not overwrite on the application form. + Only good quality Black and White passport size photograph should be pasted on the application form in coloumn No. 20, Please do not staple or pin the photograph. Ple ‘i the photograph. ‘Adilabad 13] Kadapa 12] Medak 14 | Secunderabad 23 | Ananthapur 11| Karimnagar 18 | Nalgonda 21 | Srikakaulam on Chittoor 09) Khammam 19 | Nellore 08 | Visakhapatnam 02 East Godavari 03| Krishna 05 | Nizamabad 16 | Vizianagaram 24 Guntur 06 | Kurnool 10 | Prakasam 07 | Warangal 20 Hyderabad 22] Mahabubnagar 17 | Rangareddy 15 | West Godavari 04 2. COLLEGE CODE: ‘3. NAME OF THE COLLEGE College Code shall be furnished Write full Name of the ‘Colega by the respective Principals 4&5. NAME OF THE TEACHER / FATHER’S NAME : as in P.G. Degree Centificate Leave one blank space after each initial or word in the Name. For example : KADIYALA SRAVANTHI K{a[p|tfy{aje[a] [s] Ral vjaln]t] a] 6. Sex: 7 The Date of Birth the teacher should be | | 8. Designation = MALE :M given in the space provided. Principal - 4 FEMALE: For Example, if Date of Birth is 15.11.1961 a - 8 | For Example, if Female Associate Professor- 3 5 Date of Birth[7 [5] [4] 7] [6[1 mercer =~ # D> MM YY becturee : 5 [8 F:G. Gualifcation: | HUMANITIES: MEDICAL: NURSING: M.A(Sociology) ¢ 07 | MD/MS (Anatomy) 12 [Link](N) Med/Surg -o1| M-A(Psychology) & MD (Physiology) -13, [Link](N) OBG Nursing -02| [Link] Clinical Psychology - 08 | MD (Biochemistry) -14 [Link](N) Child Health -o3| ENGLISH: MD (Pathology) -15 MSc(N) Community Health -o4| M.A (English) -09 mo nageretilogr! -16 NUTRITION: MD (Pharmacology) “17 [Link](N) i Mun) Soeciang NUSMG ~ 95) MSe(Nutntionytiome Sel. - 10 | MD (SPAUCommunity Meticine) - 18 | rs 98) [Link](Computers)/ other PG. Degree in Computers-11 [10. Year of PG __||[Link] of the Siate Council][12. Teaching Experience: || 13. Scale of Pa Completior Mention Reg. No. of respective|| Teaching Experience means, || Below Ris.10000/- 4 Please furnish thel| state council |.e. A.P. Medicall|teaching experience _after|| Rs.10001/- to Rs.15000 - 2 Year of PG Degree| ec tncivA PNursing council et, [Completion of PG Dogros. Monthsl| Fis.15007/- 0 Fis.20000 — 3 | pompletion. jcan be rounded to nearest year. || Above As.20000/- -4 [14. Local Area :][15. PAN Card No: |[16. Email Il AU - 1 |[Please furnish the|| poses tit cr 17 & 18, Phone Numbere.|[79, 20, 21 & 22 Columns: Please give your Resi-|| ri carefully and paste the| OY, <2 nserme ster JCANl oan Comma” |loenee ats vote peresnal| TcaTetly and past soos jeer eae jcc | BY FILLING THE FORM, YOU ARE AGGREEING THAT, ALL THE PARTICULARS FILLED ARE TRUE AND CORRECT AND YOU WILL BE LIABLE FOR ANY DECIPLINARY ACTION AGAINST FURNISHING WRONG INFORMATION.