mi funs’kd] ¼lkekU; ’kk[kk½ djkch fuxe] ekMWy fpfdRlky;] t;iqj APPLICATION FORM FOR CONTRACTUAL SPECIALIST & SENIOR RESIDENTS IN ESIC MODEL HOSPITAL, Designation :- Contractual Specialist / Senior Residents Specialty :- Name in full (in block letters) :- Father’s / Husband’s Name :- Affix self – attested Date of Birth :- recent passport size Sex :- Male / Female photograph here Age as on 31-08-2015 :- (photograph should be firmly pasted on this Mailing Address :- space and not stapled) (With e-mail & Teh. No.) Permanent Address :- (With e-mail & Teh. No.) (i) If person with Disability :- Yes / No (ii) Percentage of Disability :- (iii) Whether Ex- Serviceman : - Yes / No (iv) Whether ESIC/Govt. Employees : - Yes / No Community to which applicant belongs : - UR / OBC / SC / ST/ Others. Essential Educational And Professional Qualifications (Attach Annexure, if necessary) Name & University Duration Degree / Subjects Percentage No. of Attempt Address of Examination of marks College Passed obtained From To
mi funs’kd] ¼lkekU; ’kk[kk½ djkch fuxe] ekMWy fpfdRlky;] t;iqj APPLICATION FORM FOR CONTRACTUAL SPECIALIST & SENIOR RESIDENTS IN ESIC MODEL HOSPITAL, Designation :- Contractual Specialist / Senior Residents Specialty :- Affix self – attested recent passport size photograph here (photograph should be firmly pasted on this space and not stapled) Name in full (in block letters) :- Father’s / Husband’s Name :- Date of Birth :- Sex :- Male / Female Age as on 31-08-2015 :- Mailing Address :- (With e-mail & Teh. No.) Permanent Address :- (With e-mail & Teh. No.) (i) If person with Disability :- Yes / No (ii) Percentage of Disability :- (iii) Whether Ex- Serviceman : - Yes / No (iv) Whether ESIC/Govt. Employees : - Yes / No Community to which applicant belongs : - UR / OBC / SC / ST/ Others. Essential Educational And Professional Qualifications (Attach Annexure, if necessary) Name & Address of College University Duration From To Degree / Examination Passed Subjects Percentage of marks obtained No. of Attempt
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