Application Format for Asst. Prof Lecturer on Contract Basis
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Transcript of Application Format for Asst. Prof Lecturer on Contract Basis
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8/13/2019 Application Format for Asst. Prof Lecturer on Contract Basis
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Tele : JIPMER
Website: www.jipmer.eduPhone :2296022
Fax :04132272067, 2272735
JAWAHARLAL INSTITUTE OF POSTGRADUATE MEDICAL EDUCATION AND RESEARCH, PUDUCHERRY-605006.Institution of National Importance (Under the Ministry of Health & Family Welfare, Government of India)
Admn.I.(5)/2013 Date:
NOTE:
1. TO AVOID ANY MIS-REPRESENTATION
OR INTERPRETATION OF FACTS, THE
APPLICATION MUST BE SENT DULY
TYPED (IN DUPLICATE), SUPPORTED
WITH ATTESTED COPIES OF
TESTIMONIALS.
2. BRIEFOF CANDIDATE AT PAGE NO. 09TO BE SUBMITTED IN DUPLICATE
Post applied for: ASSISTANT PROFESSOR OF ______________________
1. (a) Full Name (BLOCK LETTERS):
---------------------------------------------------------------------------------
2. Fathers/Husbands Name_____________________________________________
3. (a) Mailing Address: _____________________________________________
_____________________________________________
_____________________________________________
Tel. No. __________________________ Pin: _____________________
Fax. No. _______________________ Mobile No. ______________________
E-mail ID: _______________________________________________
(b) Permanent Address_______________________________________________
________________________________________________
________________________________________________
Pin _____________________ Mobile No: ___________________________
PASTE HERE SELF
ATTESTED
LATEST
PHOTOGRAPH
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4. (a) Date of Birth: [ ] [ ] [ ]
-------------- -------------- ------------
{Date} {Month} {Year}
(b) Age: [ ] [ ] [ ]
(As on 25.06.2013) -------------- -------------- ------------
{Years} {Months} {Days}
(c) Sex: Male/Female (d) Marital Status: Married/Unmarried
(Please strike out which is not applicable) (Attach attested copy of certificate on the proforma)
5. State of Domicile : _______________________________________________
6. Nationality ___________________ Religion ___________________________
7. a) Registration No. with the Medical Council:____________________________
b) State in which registered___________________________________________
8. Educational Qualifications:
(Please attach attested copies of certificates/degrees in support of your qualifications)
QUALIFICATION:
Examination
Passed
Year of
Passing
No. of
attempts
Class/Division University/
Institution
Matric/S.S.C.
Intermediate/
HSC
M.B.B.S
1stProfl.
2ndProfl.
3rdProfl.
4thProfl.
Final Profl.
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9. EXPERIENCE: (Please attach attested copies of experience Certificates)
Post held
(indicate
Temporary/
Permanent)
Period Total period Pay
Scale
Employers Address
From To Yrs. Mths. Days
Total
11. (a) Present employment/post held :__________________________________
(b) Pay Scale :_________________________________
(c) Total emoluments drawn :________________________________
(d) Address of present employer :_________________________________
12. If Selected, what notice would you
require before joining _______________________________________
13. Have you been outside India for
Academic Purpose? If so, give
following information: _____________________________________
Country
visited
Dates of
Visit
Duration of Visit Purpose of visit
From To Yrs. Mths. Days
10. Details of Prizes, Medals,
Scholarships & National /
International Awards etc.
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14. State the foreign languages you know:
Foreign Language Can read Can write Can speak
(i)
(ii)
(iii)
15. Give below the names/particulars of two referees from your specialty who are in a position to testify from
personal knowledge to your fitness for the post.
Note: i. You should have worked with one of the referees.
ii. They must not be related to you.
iii. They must not be members of the Selection Committee of the Institute.
NAME STATUS ADDRESS
1.
2.
18. I attach attested copies of certificates/degrees in support of age, category, qualification and experience etc.as per list enclosed Annexure-I.
19 Self-evaluation of your work, particularly its strengths in different fields of activity including patient-care,
teaching research and administrative, related to the job, which, in your view, entitles you to the post applied for
may be given in Annexure-II.
Date:
Place: Signature of the candidate
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:5:
DECLARATION BY THE CANDIDATE
Post applied for ___________________________________at JIPMER, Puducherry-6. I hereby declarethat the above information is true, complete and correct to the best of my knowledge and belief. I have not
suppressed any material, fact or factual information. I understand that my candidature is liable to be rejected in
the event of any mis-statement/discrepancy in the particulars being detected and after my appointment in such
an event, my services are liable to be terminated without any notice to me or reasons thereof I am not aware of
any circumstance which might impair my fitness for employment under the Government.
Date:
Place: Signature of the candidate
DETAIL OF PARENTS/FAMILY:
NAME AGE Occupation (if in service
please mentioned
Post/Designation &
Employers Name
Gross Monthly
Income
Father
Mother
Spouse
Child
Date: Signature of Applicant
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:6:
ANNEXURE-I
LIST OF ENCLOSURES:
S.No Particulars of enclosures Marked page(s)
1. Birth Certificate
2. Matriculation Certificate
3. H Sc Certificate
4. MBBS Certificate
5. Experience Certificate(s)
6. Registration with Medical Council Certificate
7. Any other relevant certificate(s)
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:7:
ANNEXURE-II
JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION AND RESEARCH,
PUDUCHERRY-6.
(Institute of National Importance under the Ministry of Health & Family Welfare, Government of India)
Post applied for ________________________________________________________
SELF EVALUATION
Date: Signature of Candidate
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JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION AND RESEARCH,
PUDUCHERRY-605 006.
(Institute of National Importance under the Ministry of Health & Family Welfare)
Paste herelatest
Photograph
BRIEF OF THE CANDIDATE
Name Date of Birth :
Post Assistant ProfessorSpeciality :
Age as on
Year Month Day
QualificationsYear ofPassing
No. ofattempts
Institution Experience Duration Organization/Institution
Degree Level/Designation From To
MBBS
M.D./M.S.
D.M./M.Ch
D.N.B.
PGDND
PaperPublished
IndexedNon-
Indexed
Acceptedofpublication
Presented atConferences
Awards/Recognitions
National
International
Total
Chapter in Books : Any other information :
Notice period required for joining :
Place:
Date: Signature of the Candidate