Affix your
CHRISTIAN MEDICAL COLLEGE & HOSPITAL recent
VELLORE - 632 002, TAMILNADU, SOUTH INDIA Photograph
in passport size
“APPLICATION FORM”
Application for the post of
1. Name (In BLOCK Letters): :
2. Date of Birth & Age : &
3. Male / Female :
4. Marital Status: :
5. Mother Tongue: :
6. Father's Name & Occupation
7. Spouse Name & Occupation :
8. Address for Communication: :
9. Mobile Number :
10. Email ID :
11. Nationality & Religion :
12. Languages which you can speak :
Languages which you can read :
Languages which you can write :
13. Is any staff member or student of CMC past or present related to you? Yes / No
If yes, Name & Relationship :
Designation :
Department / Course of study :
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14. Your personal marks of : 1.
Identification
2.
15. In case of emergency, person to :
whom intimation should be sent
(Name Address and Contact No.)
Relationship : ________________________________
Phone / Mobile No. ____________________________
16.
Height Weight Vision Hearing
17. Were you suffering from any serious disease in the past. Yes / No
If yes, Please give details
18. Did you undergo any surgery in the past. If yes, give details Yes / No
19. Are you currently suffering from any serious disease or illness. If yes give details Yes / No
20. Whether you are a member of Employees Provident Fund Scheme Yes / No
If Yes please give your EPF Code Number.
21. Have you ever been convicted by a criminal court? Yes / No
If yes please give details.
22. Give details here of your literary, cultural, artistic games, sports etc., ability and
achievements (if any) :
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23. Please fill all the columns given below and enclose photo copies of Certificates duly notarized:
GENERAL & TECHNICAL EDUCATIONAL QUALIFICATION
S. No. Examinations, Name and Address of School or Date of Class or
Certificates, Diplomas, College University / Institution passing Division
Degrees passed or etc.
obtained
1. S. S. L. C
2.
H. S. C / +2
BACHELOR OF
3.
Regular/ Dist. Education
(Strike off which is not
relevant)
MASTER OF
4.
Regular/ Dist. Education
(Strike off which is not
relevant)
Additional
5.
Qualifications
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24. EMPLOYMENT DETAILS (PRESENT EMPLOYMENT AT THE TOP)
(Use additional sheet if necessary)
Period Served Reasons for
S. No. Name of the Company / Institution Post held leaving /
From To other remarks
25. Kindly provide two references with contact details below or attach the reference letters with
your application form.
S. No. Name, Designation & Dept. of Referee Address
Phone/Mobile:
1.
Phone/Mobile:
2.
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26. Have you ever been discharged /dismissed / removed / terminated from service. Details of
departmental disciplinary action or punishment for any misconduct in previous jobs.
(If yes, please give details) Yes / No
27. Do you agree to abide by the rules and regulations of the Institution which are in force now and
also which are to be introduced from time to time?
Yes / No
28. If selected probable date of joining:
29. I declare that all information I filled in this Application form is correct. I understand that
falsification of data will result in automatic disqualification.
Date: Signature of the Applicant
Please send the completed Application Form by hard copy to the address provided in the covering letter.
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