OFFICE OF THE PRINCIPAL
INDIRA GANDHI MEDICAL COLLEGE Photo
SHIMLA, HIMACHAL PRADESH-171001 Paste
PH. 0177-2883212, 01772883204 Here
Website:-[Link]
Sr. No. _________ Diary No. _________________________Date:____________________________
Advt. No._________________________________________________ Date:____________________
Bank Demand Draft No._____________________ Date_________________Amount_____________
1. POST APPLIED FOR: _____________________________________________
2. NAME (IN BLOCK LETTER) : _____________________________________________
3. FATHER’S/ HUSBAND NAME: _____________________________________________
4. PRESENT POSTAL ADDRESS: _____________________________________________
_____________________________________________
_____________________________________________
5. MOB. NO. 1._____________________________ 2. ____________________________________
6. EMAIL ID: ____________________________________________________________________
7. PERMANENT HOME ADDRESS: _________________________________________________
_________________________________________________
_________________________________________________
8. A) NATIONALITY: ____________________ B) GENDER ____________________________
C) CATEGORY: _______________________ D) MARITAL STATUS___________________
9. DATE OF BIRTH: ______ /______ / _________.
10. EDUCATIONAL QUALIFICATION:
S. EXAMINATION BOARD / TOTAL MARKS MARKS PERCENTAGE
NO. PASS UNIVERSITY OBTAINED
1. MATRIC
2. 10+2
3.
4.
5.
11. EXPERIENCE:
SR DEPARTMENT DESIGNATION PERIOD TOTAL
NO. NAME FROM TO EXPERINCE
1.
2.
3.
4.
5.
12. LIST OF THE CERTIFICATES AND TESTIMONALS (PLEASE ATTACH THE ATTESTED
COPIES)
(I) ____________________________________ (V) __________________________
(II) ____________________________________ (VI) __________________________
(III) ____________________________________ (VII) __________________________
(IV) ____________________________________ (VIII) __________________________
CERTIFICATE:
I hereby declare that I have carefully gone through the instruction and the contents of above
application are true and correct to the best of my ability knowledge, understanding and belief. I
understand that in the event of any information being found false or incorrect, my candidature would
be liable to be cancelled and I shall be liable for legal action in accordance with law.
Place:
Date: (Signature of Applicant)
FOR OFFICE USE ONLY
The above Candidate is Eligible or not Eligible due to _______________________________
Signature Signature Signature Signature Signature