अिखल भारतीय आयुिवर् ज्ञान संस्थान, ऋिषकेश

All India Institute of Medical Sciences, Rishikesh

APPLICATION PROFORMA

Post applied for SENIOR RESIDENT (NON-ACADEMIC)

Advertisement No. 2021/037 DATED 23rd DECEMBER, 2021

Department / Speciality PEDIATRICS

Date of Interview /
10TH JANUARY, 2022 [MONDAY] / REPORTING TIME: 9:00 AM
Reporting time

Name of bank account

Date of
holder from where Transaction No. Amount
Payment
Fee details: payment is done

CANDIDATE DETAILS:

Name of Candidate
1 ISHA KAPOOR
(in BLOCK letters)
Affix Recent
Passport Size
2 Father’s Name DR. RAJIV KAPOOR
Photograph duly
Self attested

Date of Birth
3 23-JUL-1991
(in Christian era)

(Please attach attested copy of relevant certificate)

Correspondence H.NO 1457, SECTOR 15, PANCHKULA

4
Address

5 Permanent Address H.NO 1457, SECTOR 15, PANCHKULA

6 Contact Number 9463001177 7 Citizenship indian

8 E-mail ID isha.kapoor@outlook.com 9 Gender Female

UR OBC SC ST EWS PwBD

10 Category
Y

(Please tick (√) the appropriate category and attach attested copy of relevant certificate if seeking Reservation)

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 अिखल भारतीय आयुिवर् ज्ञान संस्थान, ऋिषकेश
All India Institute of Medical Sciences, Rishikesh

11 EDUCATIONAL QUALIFICATION
Sr. Grade / Marks
Exam Passed Name of Institute Year of Passing
No. Percentage
1 Matriculation 2007 96.8
ICSE

2 Intermediate 95
CBSE 2009

*Attach separate sheet if required along with attested copies of relevant documents.

12 PROFESSIONAL QUALIFICATION
Total
Medals &
Sr. Professional Year of Name of Name of percentage No. of
awards if
No. Education Final Exam Institute University obtained / Attempt
any
Pass
PANJAB ICMR
1 MBBS 2013 GMCH UNIVERSITY studentship 64 1

PANJAB
2 MD PEDIATRICS 2020 GMCH UNIVERSITY 68.75 1

* Attempt certificate to be submitted. Attach attested copies of relevant documents.

13 EXPERIENCE CERTIFICATE
Sr.
Experience as Name of Institute Tenure Remarks
No.
1
Research Physician PGIMER AUGUST 2020- MAY 2021

*Attach attested copies of relevant documents.

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 अिखल भारतीय आयुिवर् ज्ञान संस्थान, ऋिषकेश
All India Institute of Medical Sciences, Rishikesh

Declaration

I Dr……………………………………. S/o/ D/o …………………………………….. do hereby declare and affirm that all the
statements made in this application are true, complete and correct to the best of my knowledge and belief and
nothing has been concealed thereon. In the event of any information being found false or incorrect or
ineligibility detected at any point of time, my candidature shall be liable to be rejected without any notice.

I further declare that I fulfill all the conditions of eligibility regarding age limit, educational qualification and
experience etc. prescribed for the post.

I am not employed in any other Government Institution/ Autonomous body.

OR
I am employed with ……………………………………… Government Institution/Autonomous body and if selected, I shall
join duty only after acceptance of my resignation from my current employer.

Date:-
Signature of Candidate

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 अिखल भारतीय आयुिवर् ज्ञान संस्थान, ऋिषकेश
All India Institute of Medical Sciences, Rishikesh

Enclosers:
Tick (√) as
Sr. No. Certificates
applicable
1 Date of Birth and Class X and XII Certificate Y

2 Aadhar Y

3 MBBS mark sheets Y

4 MBBS Certificate Y

5 Internship completion certificate Y

6 Attempt certificates Y

7 MD/MS/DNB certificate Y

8 MD/MS/DNB Marksheet Y

9 Experience & P.G. completion Certificate Y

10 MCI/ SMC registration Y

11 No objection certificate from present employer (if applicable)

12 SC/ST/OBC/EWS/PH certificate issued by the competent authority (if applicable)

13 Proof of deposit -Application fee

14 Publications Y

15 Copies of any other relevant documents Y

Signature of Candidate

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