FORMAT FOR APPLICATION

1. Name (IN BLOCK LETTERS) :-

2. Fathers/Husbands Name :-

3. Postal Address for Correspondence :-

4. Permanent Postal Address :-

5. Contact Telephone No. & e-mail :-

6. (i) Date of Birth (ii) Nationality

7. Category (OBC, SC, ST) :-

8. (i) For OBC Candidate please attach certificate from appropriate authority, which is
meant for the post under the Central Government of India, and Certified that the
Candidate does not belong to Creamy Layer. Date of issue of Certificate should not be
earlier than 01.01.14.

(ii) For SC, ST Certificate should be issued by Tehsildar or above rank officer in
format of State Govt./Central Govt. of India.

PH Certificate must be issued by State/Central Govt. Hospital

9. Year of passing MBBS /BDS & Name of University :-

10. Year of passing M.S. & Name of University :-

11. No. of attempts in passing Final MBBS/BDS :-

12. No. of attempts in passing Final M.S :-

13. Date of Completion of Internship and Name of Institute :-

14. Percentage (Aggregate) in Final MBBS/BDS Examination :-

15. Percentage (Aggregate) in Final M.S. Examination :-

16. Permanent DMC/DDC Registration No. & Place :-

Photo Group
17. Junior Residency (House Job) done previously,
if so period and name of Institution :-


18. UNDERTAKING:

I solemnly declare that the above statements made by me are correct to the
best of my knowledge and belief. In the event of any information found incorrect my
candidature will be liable for rejection summarily. I have not done one year Junior
Residency (Non-PG) MBBS/Six months Junior Residency (Non-PG) Dental &
Maxillofacial Surgery in any hospital.

19. Check list (Please tick in the box given below as proof of enclosures).

Final
MBBS/BDS
Marks sheet
(Part-I &II)
Permanent
Registration
Certificate
Internship
Completion
Certificate
Attempt
Certificate
All Certificates
Attested by a
GazettedOfficer






Signature of Applicant













Groups :

Group A Medicine and allied

1. Blood Bank
2. Cardiology
3. Endocrinology
4. Hematology
5. Medical oncology
6. Nephrology
7. Neurology
8. Nuclear Medicine
9. Paediatrics
10. Psychiatry
11. Resp. Med.
12. Gen. Med.
Group B Surgery and allied
1. Burns & Plastic Surgery
2. CTVS
3. Cancer surgery
4. Neurosurgery
5. Orthopaedics
6. Paed. Surgery
7. Sports Injury, Arthoscopy&Jointdisorder
8. Urology
Group C Pre &Paraclinical& Miscellaneous
1. Anaesthesia
2. Anatomy
3. Biochemistry
4. Casualty
5. Com. Medicine
6. Forensic Medicine
7. Obst. &Gyne
8. Pathology
9. Physiology
10. PMR