Dated : 16-11-2016 Walk in Interview: 02nd December 2016 APPLICATION FOR THE POST OF SENIOR RESIDENT/JUNIOR RESIDENT / TUTORS 1 Name of Candidate (In capital letters) 2 Subject 3 Sex 4 Category, SC/ST, Cat-I/ IIA/ IIB/ IIIA/ IIIB/ GM / 371(J) (Specify & attach Category Certificate) 5 Nationality 6 Postal address for correspondence (Mobile No. E-mail I.D., if any) can also be given 7 Name of Father/ Mother/ Husband: 8 Date of Birth as recorded in the SSLC Marks Card. 9 Particulars of PG registration No. with State Medical Council to be furnished. 10 Qualification prescribed for the post as per MCI 11 Specify post for which applied. PTO .. 2 .. 12 Marks/Grade Etc. Name of the Whether Aggregate of all years College & No.of Qualification Recognized Max. Marks University & Attempts by MCI Grade Marks Obtained Year of Passing 1 MBBS 2 PG 3 Diploma 4 Any Qualification 13 Teaching Experience Name of Institution / Period (DD/MM/YYYY) Total Experience Designation University From To in years & months 1 Tutor/Demonstrator 2 Senior Resident National International 14 No. of Scientific papers presented (Zerox copies of certificates to be enclosed)
Dated : 16-11-2016 Walk in Interview: 02nd December 2016 APPLICATION FOR THE POST OF SENIOR RESIDENT/JUNIOR RESIDENT / TUTORS 1 Name of Candidate (In capital letters) 2 Subject 3 Sex 4 Category, SC/ST, Cat-I/ IIA/ IIB/ IIIA/ IIIB/ GM / 371(J) (Specify & attach Category Certificate) 5 Nationality 6 Postal address for correspondence (Mobile No. E-mail I.D., if any) can also be given 7 Name of Father/ Mother/ Husband: 8 Date of Birth as recorded in the SSLC Marks Card. 9 Particulars of PG registration No. with State Medical Council to be furnished. 10 Qualification prescribed for the post as per MCI 11 Specify post for which applied. PTO .. 2 .. 12 Qualification Marks/Grade Etc. Aggregate of all years Name of the College & University & Year of Passing No.of Attempts Whether Recognized by MCI Max. Marks Marks Obtained Grade 1 MBBS 2 PG 3 Diploma 4 Any Qualification 13 Teaching Experience Designation Name of Institution / University Period (DD/MM/YYYY) Total Experience in years & months From To 1 Tutor/Demonstrator 2 Senior Resident National International 14 No. of Scientific papers presented (Zerox copies of certificates to be enclosed)
APPLICATION%20FORM-16-11-2016.docx