APPLICATION Form for PMMSSY new AIIMS Faculty Positions

(Last date for receipt of application 31st Jan 2012)

Position & Institute
1. Advertisement Number Dated 2. Applying For ( (Please check One) 3. Subjects
(Please refer the advertisement for subjects.)

Faculty new AIIMS No. 1/2011 28th Dec 2011 Professor Associate Professor 1. 2. 3. Permanent Faculty Deputation Contractual 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 Additional Professor Assistant Professor

4. Want to be considered for ( (Please check One) 5. Institute Preference:
(Please check one box for each institute)

AIIMS Bhopal p AIIMS Bhuvneshwar AIIMS Jodhpur AIIMS Patna AIIMS Raipur AIIMS Rishikesh

6 Do not consider 6 Do not consider 6 Do not consider 6 Do not consider 6 Do not consider 6 Do not consider

Name & Address
6. Applicant Name:
(Title, First Name, Middle Name, Last Name)

7. Upload Photograph
(Color passport size):

8. 9.

Birth Date:
(YYYY-MM-DD example 1962-11-19)

Sex:

Female

Male Do not want to Disclose OCI Card Holder Page 1 of 2

10. Indian Citizen: By Birth By Domicile B (Faculty newAIIMS No. 1/2011/dated 28th-Dec-2011 Form ver 1.0)

0) Page 2 of 2 . 1/2011/dated 28th-Dec-2011 Form ver 1.APPLICATION Form for PMMSSY new AIIMS Faculty Positions (Last date for receipt of application 31st Jan 2012) (Faculty newAIIMS No.

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