STATE BANK OF INDIA Central Recruitment & Promotion Department, Mumbai RECRUITMENT OF PERMANENT PART-TIME MEDICAL OFFICER – I (PPMO-I) (Advertisement No CRPD/PPMO/2016-17/15)

Application Form To,

Paste a recent passport size photograph here and sign across it in full (Please retain with you two copies of same photograph for subsequent use)

The General Manager, State Bank of India, Central Recruitment & Promotion Department, Atlanta Building, 3rd Floor, Nariman Point, Mumbai-400021

SN

Application for the Centre (please write name of centre)

1 2 3 1.

Full Name : Shri/Sat/Kum: (in block letters)

2.

Sex:

3.

MCI Registration No. & Date : ...............................................................................................................................................................

4.

a) Present Address for Communication (in block letters)

Male

Female

City:

Pin Code:

State:

b) STD Code:

Phone No:

c) Mobile No.:

5.

email-ID: _______________________@_____________(Mandatory)

Date of Birth (DD/MM/YYYY):

Age: ______Years______Months (as on 01.12.2016) (Proof to be attached)

6.

Place of birth: _________________

8.

Religion : ___________________________

9.

Father’s/Husband name: Shri

7. Nationality : ______________________

SC

10. Category to which you belong: (Tick under the correct category)

11. Whether you belong to Minority Community :

Yes

ST

OBC

GEN

No

(if ‘Yes’ mark appropriate box) Muslim

Sikh 1

Christian

Zoroastrian

Jew

Buddhist

12. Educational Qualifications (Copies of certificates to be enclosed) : SN

Course

Institution/ University

Year of Passing

13. Experience: The candidates applying for the post should enclose a one page write-up as separate annexure, describing their career and performance achievements if any with supporting documentation. Minimum 5 years’ experience as a General Practitioner reckoned as on the date of eligibility from the date of registration with the Medical Council of India (MCI). Experience gained during internship will not be counted. SN

Institution Name

From

To

Period (yy/mm)

Designation

14. Any other relevant information : _____________________________________________________________________________ _______________________________________________________________________________________________________ 15. Fees Details : Amount : Rs. 600/(i) Demand Draft No. ..................................... (ii) Date of Issue .......................... (iii) Payable at ......................... (iv) Issuing Bank .................................................................................................................................................................... 16. DECLARATION : I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found untrue or incorrect at any stage or my not satisfying any of the eligibility criteria according to requirements laid down by the Central Recruitment and Promotion Department, my candidature is liable to be cancelled. I am willing to serve anywhere in India including rural area.

Place: ______________

Signature: _________________________________

Date: ______________

Name of Candidate: _________________________ (in block letters) LTI

Both Signature & Left Thumb Impression (LTI) are compulsory

Application with required documents must reach above address on or before 06.02.2017 Enclosure:

1. 2. 3. 4. 5. 6. 7. 8.

Demand draft No. .................................. Dated ............................ amount .............................. Proof of age (Copy of 10th standard/ 12th standard certificate showing the Date of Birth). PAN Card Proof of education certificate. Copy of registration certificate issued by Medical Council of India, Experience certificate Cast certificate issued by competent authority on format prescribed by the Government of India in case of SC/ST. OBC Certificate containing the ‘Non- Creamy Layer’ clause issued by the competent authority during the period 0104-2016 to the date of interview. (For OBC- Non Creamy Layer applicants). 9. Brief write-up / Resume as separate annexure, describing career and performance achievements in service and details of gallantry awards/medals if any with supporting documents. 10. Candidates serving in Government/ Quasi-Government offices, Public Sector undertaking including Nationalised Banks and Financial Institutions will be required to submit “No Objection Certificate” from the employer at the time of interview 2