application format for asst. prof lecturer on contract basis

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

application format for asst. prof lecturer on contract basis

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