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    1733831591_advertisement

    Uploaded by

    Subhasish Dash
    3 views3 pages

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    Copyright:

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    Download as docx, pdf, or txt
    3 views3 pages

    1733831591_advertisement

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    Subhasish Dash

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Indian Council of Medical Research

    Application for engagement of Project Positions, purely on temporary contract basis

    1. Name of the Position, applied : __________________________


    for Latest photograph

    2. Advertisement No. : __________________________

    3. Name in full (IN BLOCK :


    LETTERS)
    __________________________

    [SURNAME] [NAME]
    [FATHER/HUSBAND]

    4. Mother’s Name : ______________________________________

    Father’s Name : ______________________________________

    Husband’s Name : __________________________

    5. Address for Correspondence : ______________________________________________

    ______________________________________________
    ______________________________________________

    ______________________________________________

    Contact No.____________________________________

    Email id: ______________________________________

    6. Permanent Address : ______________________________________________

    ______________________________________________

    ______________________________________________

    ______________________________________________

    7. Date of Birth [dd/mm/yyyy] : ________________________ Age : _________________


    (Certificate must be
    supported)

    8. Whether SC/ST/OBC/General : ________________________ Caste: ________________

    9. Marital Status : Married / Unmarried / divorcee / widower / widow

    10. Educational Qualifications : (Certificates in proof of qualifications must be supported).

    SN EXAM. PASSED GRADE YEAR OF BOARD / SPECIALIZATION


    PASSING UNIVERSITY

    11. Work Experience (Certificates in proof of experience must be supported):

    Name of Employer Post From date To date Reason for


    leaving
    Total Experience gained after acquiring the minimum essential qualification (in years): _________

    12. Details of NET/GATE/National level exams passed, if any.


    Exam passed Date of passing Valid till

    13. If selected what period would you require to join: _____________________

    Note: Additional information, if any can be provided on a separate paper or on overleaf of this
    page.

    Declaration: I hereby declare that the particulars furnished in this form by me are true to the best of
    my knowledge and belief. Furnishing of false information or suppression of facts will be
    disqualification and is likely to render the candidate unfit.

    Date: ___________________ Signature: _____________________________

    Place: ___________________ Name of the candidate: __________________

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