All India Institute of Medical Sciences Bhopal Saket Nagar, Bhopal 462020 ANNEXURE -A

Affix you recent coloured passport size photograph with signature

APPLICATION FORM FOR THE POST OF TUTOR/DEMONSTRATOR

1.

Advt. No. AIIMS/Bhopal /2018/05

2.

Post applied for ………………………Department…………………..

3.

Name (in Block Letters) …………………………………………………………

4.

Father’s/Husband’s Name ……………………………………………………..

5.

Mother’s Name .…………………………………………………………………...

6.

Address (Permanent) .………………………………………......................... ………………………………………………………………(Address proof to be enclosed)

7.

Address for correspondence ………………………………………………………………………..… …………………………………………………………………………… Contact No. ……………………

Mobile No. ……………..…………..

E-mail (in capital)………………………………………………….

8.

9.

10.

Date of Birth:

(dd/mm/yy)

Category: (GEN/SC/ST/OBC/PwD-OPH)……………………………………………………

Age as on date of Interview: (dd/mm/yy)

11.

Gender : Male/Female

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12.

Educational/ Professional Qualification: Degree/Exam.

13.

Year of

University

Passing

Subject

Percentage /Division

Work Experience: Sr. No

14. 15.

Name of Board/

Name of Department/

Name of the

Date of

Date of

Section

post held

Joining

Leaving

Whether MBBS/M.D./M.S. degree is recognized by Medical Council of India: Yes/No Whether registered with State Medical Register or Indian Medical Council : Yes/No (Attached the copy of registration) A) Registration No. ……………………….. B) State in which registered. ……………………………

16. Fee Details:

D.D. No. ____________________ Amount (in Rs.) _________________

Dated ______________

Bank Name ______________________________ DECLARATION

I hereby declare, that all statements made in this application are true, complete and correct to the best of my knowledge and belief. In the event of any information being found false or incorrect my candidature is liable to be cancelled/ terminated. I will have no claim for absorption after termination/ completion of tenure contract. I shall abide by terms & condition as prescribed. In the event of ineligibility being detected before or after the selection procedure, action can be taken against me under the relevant rules/instruction and hereby undertake to abide by them. Date: Place:

(Signature of Candidate) Name:………………………………..

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Check list of documents required at the time of interview in original and one set photocopy: Sl.No. 1 2 3 4 5 6 7 8 9 10

Copy of the Certificate Class X & XII certificate for Date of Birth MBBS/M.Sc. Mark Sheet & Certificate Internship Completion Certificate MD/MS/DNB/ /Ph.D Mark sheet State/MCI registration SC/ST/OBC/PH certificate issued by the competent Authority ( If applicable) Attempt Certificates Photo Identity Proof Photographs 2 Nos Copies of any other relevant documents

Please Tick

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