अखिल भारतीय आयर्वज्ञान सस्थान नागपर

ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NAGPUR

Address: Plot No. 2, Sector - 20, MIHAN, Nagpur - 441108
Website: www.aiimsnagpur.edu.in
No.AIIMS/NGP/Admin I/Faculty/2020/01

Issuing Bank Demand Draft No. Date Amount

NOTE:
1. TO AVOID ANY MIS-REPRESENTATION OR
INTERPRETATION OF FACTS, THE PASTE HERE
APPLICATION MUST BE SENT DULY LATEST
‘TYPED’, SUPPORTED WITH ATTESTED SELF ATTESTED
COPIES OF TESTIMONIALS. PHOTOGRAPH

2. BRIEF OF CANDIDATE TO BE
SUBMITTED AS PER ANNEXURE – I

Application for the Post of

Discipline
I. CANDIDATE DETAILS

1 Full Name (BLOCK LETTERS

as given in the Birth certificate)
2 Father’s Name
3 Mailing Address

4 Mobile No
5 Telephone No.
6 Email address
7 Aadhar No
8 Permanent Address
 9 Date of Birth (dd/mm/yyyy)

10 Age (as on 17.03.2020) Years Months Days

11 Gender

12 Marital Status
13 Whether Orthopedic Physically
Handicapped (OPH) (Yes/No)
Attach attested copy of
certificate on the proforma
14 Percentage of disability

15 Category under which applied

(UR/SC/ST/OBC/EWS)
16 State of Domicile

17 Nationality

18 Religion

II. EDUCATIONAL QUALIFICATIONS:

(Please attach attested copies of certificates/degrees in support of your qualifications)

(a) Undergraduate Career

Medical
Examination Year of No. of University/ Council
Class/Division
Passed Passing attempts Institution Registration
No.

Matric/S.S.C.

Intermediate/
HSC

B.Sc

M.B.B.S
(b) Postgraduate Career:

Year of No. of University/

Examination Passed Class/Division
Passing attempts Institution

M.D./M.S.
 M.Sc.

D.M/M.Ch.*

D.N.B.

Ph.D.

* Must indicate No. of years of the course (2yrs/3yrs/5yrs) and name of the Institute with full
address.

III. TEACHING/RESEARCH EXPERIENCE:

(Please attach attested copies of experience Certificates)

After obtaining Postgraduate/Super Specialty/Ph.D. Qualification including present

employment:
Post held Period Total period
(indicate Employer’s
Sl.No. Pay Scale
Temporary/ From To Yrs. Mths. Days Address
Permanent)
1.

2.

Total
 IV. ACHIEVEMENTS:

1 Details of Prizes, Medals,

Scholarships & National /
International Awards etc.

2 Additional qualification such as

Membership of Scientific Society
etc.

3 Research Experience, if any,

together with details of published
works in indexed journals.
4 Details of Research projects
with extramural funding
5 No. of Papers presented at National
conference
6 No. of Papers presented at
International conference
7 No. of Papers published (Original
articles/Review articles)
7a Indexed
7b Non-Indexed
8 No. of Papers accepted for
publication (Original
articles/Review articles)
9 No. of Chapter in books/books
edited
10 If Selected, what notice
period would you require before
joining
11 Have you been outside India
for Academic Purpose? If so,
give following information:
13a) Please provide a list of all your scientific publications in chronological order
providing details of articles including whether Original article/review/case report, indexed / non-
indexed, impact factor and number of citations for the articles:
Type Indexed in Impact
Sl. No. Particulars of Article (In Vancouver format) Factor of Citations
the Journal

13b) Please provide a list of all your chapters in books/ books edited in chronological order:

Sl. No. Particulars of Chapter/ Book (in Vancouver format)

14. State the foreign languages you know:

No. Foreign Language Can read Can write Can speak

(i)

(ii)

(iii)

15. Give below the full details of 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 for at least two years.
ii. They must not be related to you

NAME STATUS ADDRESS

I attach attested copies of certificates/degrees in support of age, category, qualification and

experience etc. as per list enclosed Annexure-III.

Date: Signature of the candidate

Place:

NOTE:

1. INCOMPLETE APPLICATION AND THE APPLICATION RECEIVED WITHOUT

DEMAND DRAFT OF THE REQUIRED AMOUNT WILL NOT BE CONSIDERED.

2. SUBMIT ALONG WITH APPLICATION, ONE ATTESTED PHOTOCOPIES

OF DOCUMENT REFERRED AT POINT NO.2 OF GENERAL CONDITIONS PUBLISHED
IN WEBSITE ADVERTISEMENT.
 DECLARATION BY THE CANDIDATE

(Post applied for of Discipline at

AIIMS, Nagpur).

I hereby declare that 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 on regular basis.

Date: Signature of the candidate

Place:
Annexure- III
LIST OF ENCLOSURES

S.No Particulars of enclosures Attached (Yes/No)

1.
Birth Certificate

2.
Matriculation Certificate

3. Mark sheets of MBBS/M.Sc for all years

4.
MBBS Degree Certificate

5.
M.D/M.S./DNB/M.Sc Degree Certificate

6.
D.M./M Ch. Degree Certificate
7.
Experience Certificate(s)

8. Community Certificate (SC,ST / OBC (Non- Creamy

Layer)
Income and Asset certificate in case of EWS
9
candidates

10 Registration & Additional Registration with

Medical Council Certificate

11. Disability Certificate

12.
Any other relevant certificate(s)
Candidates already employed in Central/State
Govt./Autonomous Institutions / Statutory Organizations/ PSUs under
Central/ State Govt. should get the following endorsement signed by their
present employer (appointing authority).

NO OBJECTION CERTIFICATE
1. Certified that holds a post of for the period
from

till date on regular basis in Department. I have no

objection to his/her application being considered for the post of in

the department of in AIIMS, Nagpur. In the event of his / her

selection to the post, he / she will be relieved from the duty to take up the post of

in AIIMS, Nagpur.

2. Certified that he/she submitted his/her application to the Department /Office/

Institution/Organization on for onward transmission to AIIMS, Nagpur -

440003.

No. Signature

Dated Designation
(Seal with Name & Designation)

Office Stamp
 DECLARATION TO BE SIGNED BY OBC CANDIDATES ONLY
I son/daughter Shri resident of
Village/ Town/ City/ State
District
Community_ (certificate enclosed) hereby declare that I
belong to the community which is recognized as a backward class by the
Govt. of India for the purpose of reservation in services as per orders contained in
Department of Personnel and Training Office Memorandum No.36012/22/93-Estt(SCT)
dated 8.9.1993. It is also declared that I do not belong to the persons/sections (creamy layer)
mentioned in Column3 of OM No. 36012/22/93-Estt(SCT) dated 08.09.1993 and modified
vide Govt. of India, Department of Personnel and Training OM No.36033/3/2004-Estt(Res)
dated 09.03.2004.

Place:
(Signature of applicant)
Date: (In running handwriting)
 FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES
APPLYING FOR APPOINTMENT TO POST UNDER THE GOVERNMENT OF INDIA

This is to certify that Shri / Smt. / Kum* son / daughter

of shri of village / town in
District in statebelongs
to community which is recognised as a backward class under :-

(1) Resolution No.12011/68/93-BCC© dated 10th September 1993, published in the Gazette of India -
Extraordinary -part 1, Section 1, No.186 dated 13th September 1993.
(2) Resolution No.12011/9/94-BCC dated 19th October 1994, published in the Gazette of India - Extraordinary
– part1, Section 1, No.163, dated 20th October 1994.
(3) Resolution No.12011/7/95-BCC, dated 24th May, 1995, published in Gazette of India - Extraordinary - part
1,Section 1, No.88, dated 25th May 1995.
(4) Resolution No.12011/44/96-BCC, dated 6th December 1996, published in Gazette of India - Extraordinary
- part 1,Section 1, No.210, dated 11th December 1996.
(5) Resolution No.12011/68/93-BCC, published in Gazette of India - Extraordinary - No.129, dated the 8th
July 1997.
(6) Resolution No.12011/12/96-BCC, published in Gazette of India - Extraordinary - No.164, dated the
1st
Sept 1997.
(7) Resolution No.12011/99/94-BCC, published in Gazette of India - Extraordinary - No.236, dated the 11th
Dec 1997.
(8) Resolution No.12011/13/97-BCC, published in Gazette of India - Extraordinary - No.239, dated the 3rd
Dec 1997.
(9) Resolution No.12011/12/96-BCC, published in Gazette of India - Extraordinary - No.166, dated the 3rd
Aug 1998.
(10) Resolution No.12011/68/93-BCC, published in Gazette of India - Extraordinary - No.171, dated the 6th
Aug 1998.
(11) Resolution No.12011/68/98-BCC, published in Gazette of India - Extraordinary - No.241, dated the 27th
Oct 1999.
(12) Resolution No.12011/88/98-BCC, published in Gazette of India - Extraordinary - No.270, dated the 6th
Dec 1999.
(13) Resolution No.12011/36/99-BCC, published in Gazette of India - Extraordinary - No.71, dated the 4th
April 2000.

Shri/Smt./Kum* and/or his/her family ordinarily reside(s)

in the District of the State. This is also
to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned
in column 3 (of the Schedule to the Government of India, Department of Personnel & Training
OM NO.36012/22/93 –Estt(SCT), dated 08.09.1993) and modified vide Government of
India, Department of Personnel and training O.M No.36033/3/2004-Estt.(Res) dated 09.03.2004.

Place :
Signature
Dated : District Magistrate/Dy. Commissioner
etc.
*Strike out whichever is not applicable (With seal of office)
NB: (a) The term 'ordinarily' used here will have the same meaning as in section 20 of the
Representation
of People’s Act., 1950.
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- The Authorities competent to issue OBC caste certificates are indicated below :-
(i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner /Additional
Deputy
Commissioner / Deputy Collector / 1st class Stipendiary Magistrate / Sub - Divisional Magistrate
/ Taluk Magistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank of
1st class Stipendiary Magistrate).
(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate/ Presidency
Magistrate.
(iii) Revenue Officer not below the rank of Tahasildar, and
(iv) Sub-Divisional Officer of the area where the Candidate and or his family resides.