Last Date for Receipt o f A pplication

Regional Ayurveda Research Institute for M other and C h ild Health Near G h ark ul Parisar, N IT Complex, N andanwan, N agpur - 09 A P P L IC A T IO N F O R M 1. Nam e o f the post applied for A recent passport Advertisement No.

size photograph to be a

2. Nam e and Address

xed in this space

(in Block letters)

3. Date o f Birth

_______________________________

(in Christian Era) 4. Sex

M ale

Female

5. C om m unity (W hether S C /ST /O B C /O thers)______________________ 6. Educational Qualifications (Starting from H igh School) S. No

Examination Passed

Year

Name o f the School/College/ Universitv

1

Attempts

Dvn.

Subjects.

7. Experience S. No.

N am e o f Post

Scale o f Pay

N am e o f the Department

8. Total No. o f Papers/Monographs Published (G ive details)

9. Seminars/Symposium/ Workshop attended (N ational/International: I.

2.

3. 2

Period From

To

Nature o f W ork

10. Specialization, if any

Details o f Enclosures: I.

2.

______________________________________________________________________

3.

______________________________________________________________________

4.

______________________________________________________________________

I herb) declare that all statement made in this application are true and complete to the best o f knowledge and belief. I understand that action can be taken against me by the C ouncil I f I am declared to be guilty o f any type o f misconduct mentioned herein. I have informed by Head Office/Department in writing that I am apply ing for selection to the post.

Signature o f the Candidate N a m e ______________________ Date: Place:

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If employed, a Vigilance clearance certificate as given below should be given by the Department. Certified that Shri/Sm t./Kum ari/D r.

________________________________________

O f ________________________________________________________________________________________ holds a temporary/permanent post o f _____________________________________________________________________ in the Department o f ______________________________________________________________________________ and that no disciplinary case is pending or contemplated against him/her.

No.

Signature________________________

Date

Designation O ffice Seal

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