Beruflich Dokumente
Kultur Dokumente
Application Form
To,
Paste a recent
passport size
photograph here
and sign across it in
full
(Please retain with
you two copies of
same photograph
for subsequent use)
SN
1
2
3
1.
2.
Sex:
3.
4.
Male
Female
City:
Pin Code:
State:
b) STD Code:
Phone No:
c) Mobile No.:
5.
email-ID: _______________________@_____________(Mandatory)
6.
8.
Religion : ___________________________
9.
7. Nationality : ______________________
SC
10. Category to which you belong: (Tick under the correct category)
Yes
ST
OBC
GEN
No
Sikh
1
Christian
Zoroastrian
Jew
Buddhist
Course
Institution/ University
Year of Passing
13. Experience: The candidates applying for the post should enclose a one page write-up as separate annexure, describing their career
and performance achievements if any with supporting documentation. Minimum 5 years experience as a General Practitioner
reckoned as on the date of eligibility from the date of registration with the Medical Council of India (MCI). Experience gained during
internship will not be counted.
SN
Institution Name
From
To
Period (yy/mm)
Designation
Place: ______________
Signature: _________________________________
Date: ______________
Application with required documents must reach above address on or before 06.02.2017
Enclosure:
1.
2.
3.
4.
5.
6.
7.
8.