Application Form

Post Applied For:Department:

Name in full:

Father's/Husband's Name:

Present Address:

Mobile No:

Permanent Address:

Tel. No:

E-Mail Address:

Age:

Birthday:

Category Applied for:

1) Full particulars of general and Technical qualifications acquired commencing from S.S.C./H.S.C./MBBS/BDS/PG or equivalent examination. (Please mention about the successfully completed courses only.)

Name of Exam. Degree or Course	School / College / University	Year of Passing	Class / Division	Principal Subjects offered	Merit / rank & % of Marks	Nos. of Attempt

2) Any professional/other training taken details with duration and name of institute::

3) Details of membership of any professional/academic Institute

4) Expected starting total salary including allowances: Rs. (per Annum)

5) When can you join if offered an appointment?

6) Details of the previous appointment/teaching experience
(Attach Certificate without which experience will not be counted)

Designation	Department	Name of Institution	Form DD/MM/YY	To DD/MM/YY	Total Experience in year & months
Register/ Sr.Residency/ Resident
Tutor/ Demonstrator/ Lecturer(DENTAL)
Assistant Professor/ Reader
Associate Professor
Professor

7) No. of Research publication in Journals as per the requirement of MCI: (attach separate sheet of details as under mentioned, along with copy of Research Publication and proof of Indexing without which it will not be counted - As per Annexure - A

8) Are you having service agreement/Bond with your present employer?
If yes, please mention period etc. and give details separately.

YesNo

9) Have you been abroad?
If yes, please mention countries visited with purpose & duration.

YesNo

10) Languages Known

Mother tongue:

Speak	Read	Write
Speak	Read	Write
Speak	Read	Write
Speak	Read	Write
Speak	Read	Write

11) Physiology Details:

Height	Weight	Sex
Religion	Nationality	Domicile
Marital Status	No. of Children

Disability of permanent nature or chronic illness, if Any
Identification marks
Wearing Glasses? If yes please mention Number & Duration

12) Please name two references who are not your relative and who can certify your work and conduct with
contact No. & Address

13) Any other relevant Information

I solemnly declare that the particulars furnished in this application are true and correct. I clearly understand that any misstatement of fact contained herein or willful concealment of any material fact will render me liable to appropriate acton as may be decided by AMC MER.

Candidate should furnish with this application ture copies of all the mark sheets, certificates, attempt Certificates, testimonials of education qualification form S.S.C. onwards and experience and copies of research publication along with proof of indexing, etc. duly certified
Application with incomplete information will not be accepted. if any way accepted it will be treated as canceled without further communication.
The application should be in the candidate's own handwriting
A candidate who is employed elsewhere should forward the application through his/her employer and should attach a certificate form the employer that he/she has been permitted to apply for the post in queastion. otherwise the application will not be considered

Place:

Date:

Signature:

14) Annexure - A

Sr.	Title of Research Paper	Type of Artical	Name of journal	Authorized Publication of Which Society?	National / International	Name of Indexing Agencies	As Author First / Second	Place form where journal is published?

Signature of Applicant:

15) ENCLOSURES

Sr. No.	Documents	Type of Artical
1	Proof of Birth Date	YesNo
2	Caste Certificate	YesNo
3	SSC Marksheet	YesNo
4	HSC Marksheet	YesNo
5	1^st MBBS / BDS Mark Sheet[inculding mark sheet of failure]	YesNo
6	2^nd MBBS / BDS Mark Sheet [inculding mark sheet of failure]	YesNo
7	3^rd MBBS / BDS Mark Sheet [inculding mark sheet of failure]	YesNo
8	4^th BDS Mark Sheet [If Applicable]	YesNo
9	MBBS / BDS Attempt Certificate(s) for all years	YesNo
10	MBBS / BDS Degree Certificate	YesNo
11	PG Mark Sheet(s)	YesNo
12	PG Degree Certificate	YesNo
13	PG Attempt Certificate	YesNo
14	Letter form head of institute regarding recognized degree	YesNo
15	Copies of Registration of MBBS / BDS and PG Degree	YesNo
16	Teaching Experience Certificate In absence of it, experience will not be taken in to account	YesNo
17	Copies of Publications	YesNo
18	Proof of Indexing for publication(s)	YesNo
19	Copy of PAN Card	YesNo
20	Copy of Aadhar Card	YesNo

Candidate has to check / about all details and attachment, before submitting application. Application with deficient details or attachment will be treated as rejected without any communication.

If any communication will be needed, it is throught E-mail only hence kindly recheck your email address.

Signature of Applicant:

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