भारतीय ौ ोिगक सं थान खड़गपुर
INDIAN INSTITUTE OF TECHNOLOGY KHARAGPUR
APPLICATION FORM
Advt. No.: R/08/2025 Self attested
photograph
Post applied for
Specialization
A. PERSONAL DETAILS :
1. Candidate’s Name in full (in CAPITAL letters)
2. Father’s Name
3. a) Marital Status b) Gender
4.
a) Permanent Address: b) Correspondence Address:
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
Dist.: _____________________________________ Dist.: _____________________________________
State: _____________________________________ State: _____________________________________
PIN Code: __________________________________ PIN Code: __________________________________
Phone No.: _________________________________ Phone No.: _________________________________
E-mail: ____________________________________ E-mail: ____________________________________
5. Date of Birth
6. Nationality
7.
Category (GEN/SC/ST/OBC/EWS/PwD)
8. Medical Registration No. (as applicable)
9. Name of the Medical Council (as applicable)
B. ACADEMIC QUALIFICATION :
Examination/ Name of the Board / Passing Percentage No. of
Sl#
Degree passed University / Institution Year of marks attempts
1.
2.
3.
4.
5.
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C. FULL TIME TEACHING EXPERIENCE :
Name of the Organization / Employment Employment period
Sl# Post held
Institution From To (in year/month)
D. WORK EXPERIENCE :
Mention only experience as Consultant or Specialist, or Medical Officer working in a non-
teaching Government hospital having at least 220 beds (Please don’t mention any working
experience in any private/corporate hospital):
Name of the Employment Employment period
Sl# Name of the Hospital No. of beds
post From To (in year/month)
E. RESEARCH PAPERS/PUBLICATION DETAILS :
(as per NMC publication criteria time to time)
Sl# Name of Article and Authors Journal name and index Month, year of publication
F. BOOK CHAPTER CONTRIBUTION DETAILS:
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G. PATENTS DETAILS:
H. AWARDS /FELLOWSHIP DETAILS:
I. RESEARCH PAPERS/PUBLICATION DETAILS :
Date of appearance in last NMC assessment:
Name of the college / Institution:
Whether appeared and accepted as medical
teacher (Y/N):
Appeared as UG/PG/other Teacher (UG/PG):
I hereby declare that the details mentioned in this form are true to the best of my knowledge and I shall be
able to produce documents if asked for.
Place : _____________
Date :______________
_____________________________
Applicant’s Signature
To
Registrar
Indian Institute of Technology Kharagpur
Kharagpur – 721302
West Bengal
India
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