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Application With Bio Data

This document is an application form for the position of Senior Resident at Jawaharlal Institute of Postgraduate Medical Education and Research, requiring personal, educational, and professional details from the applicant. It includes sections for biographical information, qualifications, experience, and an undertaking of truthfulness. Incomplete applications may be rejected, and specific documentation must be attached for verification.

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Arun Anbu
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2 views2 pages

Application With Bio Data

This document is an application form for the position of Senior Resident at Jawaharlal Institute of Postgraduate Medical Education and Research, requiring personal, educational, and professional details from the applicant. It includes sections for biographical information, qualifications, experience, and an undertaking of truthfulness. Incomplete applications may be rejected, and specific documentation must be attached for verification.

Uploaded by

Arun Anbu
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

ANNEXURE - I

JAWAHARLAL INSTITUTE OF POSTGRADUATE MEDICAL EDUCATION AND


RESEARCH, PUDUCHERRY- 605 006.
(An Institute of National Importance under Ministry of Health & Family Welfare, Government of India)

Application form with Bio-data


Application form No. (For Office use only) Affix recent
passport size
Details of Application fee: photograph duly
UTR/Transaction ID,Date, Name of the Bank & Amount self-attested

Note: In-complete application is liable to be rejected.

1. Application for the post of Senior Resident in ________________________________________


(Subject/Specialty)
2. Applicant’s Name (IN BLOCK LETTERS)

3. Father’s/Husband’s Name (IN BLOCK LETTERS)

4. i) Date of Birth of Applicant


(Attach proof) DAY MONTH YEAR

ii) Age: (as on the crucial date)

5. Category of the candidate: (Attach proof of SC/ST/OBC/EWS)

6. Applied under Category

7. Nationality: Religion: Marital Status:

8. Educational/Academic/Technical/Professional Qualifications (Attach proof):-


Year of
Passing with No. of
Examination Passed Subject
Name of College / Institution Name of University % of attempts
Marks
*M.B.B.S./BDS

*M.D./M.S/DNB/MDS

*DNB/[Link]./D.M

* Please attach proof of Recognition of MBBS/MD/MS degree by Medical Council of India. Candidates
possessing Degree/PG degree not recognized by MCI will not be allowed to appear for interview.
9. No. of papers published: National International
10. Details of prizes, Medals, Scholarships & National/ International Awards and Additional
Qualification such as members of scientific society etc.

11. Chronological details of up to date appointment after obtaining postgraduate qualification


(attach experience certificate)
Post held From To Organization/Employer’s Name
& Address

12.
(a) Permanent NMC/DMC/State Registration No.(attach proof) : _______________

(b) Name of the Council & Validity: _______________________________

13. Period of one year Compulsory Internship /CRRI: From ___________________To___________________

14. Date of completion of PG degree: ____________15. Date of completion of Junior Residency: _______________

16. Permanent Address 17. Correspondence Address:

Pin Code: Pin Code


Mobile No: Mobile No:
E. Mail I.D.: E. Mail I.D.:
Aadhar No.

UNDERTAKING
I solemnly affirm and declare that the particulars furnished above in Sl. Nos. 1 to 17 are true, correct, and complete to the
best of my knowledge and belief, and that nothing has been concealed therefrom. I further undertake that in the event of
any information being found to be false or incorrect, I shall be liable for appropriate action as per the rules in force.

Place: Signature: ____________________________________________

Date: Name: _______________________________________________

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