कर्मचारी राज्य बीर्ा निगर् क०रा०बी०नि०निनकत्सा

महानिद्यालयएिंअस्पताल- नबहटा,
(श्रर् एवं रोजगार र्ंत्रालय, भारत सरकार) पटिा,नबहार - 801103
EMPLOYEES’ STATE INSURANCE
CORPORATION
ESIC Medical College &
क. रा. बी. नि. (Ministry of Labour & Employment, Govt. of Hospital;Bihta, Patna, Bihar-801103
India) e-mail: dean-bihta.bh@esic.nic.in
E. S. I. C.

Format of Application

(Fill form with black ink in BOLD letters, scan and mail to esicmchbihta@gmail.com)

. Post applied for (Faculty with Post /Senior Resident):-

• Department applied for:

Affix recent
self attested
passport size
photograph.

• Name in block letters: Sex: M/F/Other

• Father’s/Husband’s name:

• Date of Birth, Age as on Date of Interview(28th June 2022):

• Category(please tick ) :- SC( )/ST( )/OBC( )/UR( )/EWS( ): Specify (caste) :

• Post Notified Under Category:

• Qualifications (MBBS/MD/MS/DNB/PG Diploma etc. with Certificates)

Please add rows and columns as per requirement in table:

Sr.No. Qualifications College Board/University Year of Posting Marks Division Attempts

Experience (as per the post notified) Govt. /Pvt. Hospital/Institution (in Years / Months) with Certificates:

1.

2.

3.

4.

5.

6.

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 • MCI/State Regn. no.:

• Telephone No: Res.: Mobile:

• E-mail:

• Permanent Address:

• Present Residential Address:

• Whether Married/Unmarried:

• Nationality & Mother Tongue

• Blood Group:

• PAN Card No. Aadhar No:

• Height: Ft. Inches

• Identification Mark:

DECLARATION:

I undertake that all the above information given above by me is correct to the best of my knowledge and I
solemnly affirm that if any information given by me, if found wrong at any stage, my candidature for the post will
automatically stand cancelled.

Date: (Signature of Candidate)

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 Check List of enclosures attached:-

1. Date of Birth Certificate (Matriculation) : Yes/No

2. Proof of Identity (Aadhar/Pancard/Driving License /other : Yes/No

3. MBBS Certificate with Attempt Certificate : Yes/No

4. Diploma / PG Certificate (MD/MS/DNB/PG Diploma) : Yes/No

5. MCI / State Registration Certificate : Yes/No/N.A

6. Experience Certificate, if applicable : Yes/No/N.A
(Attachment of Experience Certificate from immediate employer mandatory wherever applicable)
7. NOC, if applicable : Yes/No/N.A
(Attachment of NOC from immediate employer mandatory wherever applicable)

7. Research Publications, if applicable

(Attach photocopies of all publications mentioned for consideration) : Yes/No/N.A

8. Caste (SC/ ST/ OBC/ EWS) Certificate (latest), if applicable : Yes/No/N.A

9. Residential Address Proof : Yes/No

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 Important
(Read before filling forms)

• Only one form should be filled / submitted by candidate for one discipline.
• Incomplete applications are liable to be rejected.
• Forms should be filled by candidate in person with clear and capital letters.
• Photograph should be with clearly visible face, both ears & signed across.
• All documents with self attestation must be scanned and sent as PDF ONLY arranged
in sequence as per check list latest on or before 27th June 2022 by 1:00 pm or can be
submitted on day of Interview in person.
• No separate interview call letter will be sent.
• Non refundable application fee will be charged Rs. 225/- only (exempted for reserved and female
candidates)
• Canvassing in any form will debar the candidature at any stage.
• Appointment letter will be issued on the day of announcement of results.
• All candidates should report at 9:00 AM on 28th June 2022 at Reception, Medical
College Building, ESIC Bihta with two sets of forms and documents submitted and
original certificates for verification
• The ESIC reserves the right to cancel the recruitment process at any stage at its
discretion and such decisions will be binding on concerned.

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