Application Form html

Your Photo:

Post Applied For: Department:

Name in full:

Father's/Husband's Name:

Present Address:

Mobile No:

Permanent Address:

Tel. No:

E-Mail Address:

Birthdate:

Age:

Category Applied for:

1) Full particulars of general and Technical qualifications acquired commencing from S.S.C. / H.S.C. / MBBS / BDS / PG / MCH / DM / PHD / DNB / MD / MS / MDS / MPT / BPT / PSC Nursing / MSC Nursing / BSC Nursing or equivalent examination.
For more then i attempt all mark sheets should be submitted (including failure mark sheets)

Name of Exam. Degree or Course	School / College / University	Year of Passing	Class / Division	Principal Subjects offered	Marks obtained	Total Number of Marks	Percentage obtained	Nos. of Attempt

2) When can you join if offered an appointment?

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

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

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

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

6) Languages Known

Mother tongue:

Languages	Speak	Read	Write

7) 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

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

9) No. of Research publication in Journals as per the requirement of MCI fill the details in below mentioned Annexure - A, along with copy of Research Publication and proof of Indexing without which it will not be counted.

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 / corresponding	Research Paper	Place from where journal is published?

10) ENCLOSURES

Sr. No.	Documents	Type of Artical
1	Proof of Birth Date	Yes No
2	Caste Certificate	Yes No
3	SSC Marksheet	Yes No
4	HSC Marksheet	Yes No
5	1 ^st MBBS / BDS Mark Sheet[inculding mark sheet of failure]	Yes No
6	2 ^nd MBBS / BDS Mark Sheet [inculding mark sheet of failure]	Yes No
7	3 ^rd MBBS / BDS Mark Sheet [inculding mark sheet of failure]	Yes No
8	4 ^th BDS Mark Sheet	Yes No
9	MBBS / BDS Attempt Certificate(s) for all years	Yes No
10	MBBS / BDS Degree Certificate	Yes No
11	PG Mark Sheet(s)	Yes No
12	PG Degree Certificate	Yes No
13	PG Attempt Certificate	Yes No
14	DM/MCH Marksheet & Certificate	Yes No
15	Copies of Registration of MBBS / BDS / BPT / BSC Nursing	Yes No
16	Copies of Registration of MD / MS / MDS / MPT / MSC Nursing	Yes No
17	Copies of Registration of DM / MCH / PHD	Yes No
18	Teaching Experience Certificate In absence of it, experience will not be taken in to account	Yes No
19	Copies of Publications	Yes No
20	Proof of Indexing for publication(s)	Yes No
21	Copy of PAN Card	Yes No
22	Copy of Aadhar Card	Yes No
23	Other Document	Yes No
24	Other Document	Yes No
25	Other Document	Yes No

11) 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 MET.

Candidate should furnish with this application ture copies of all the mark sheets, certificates, attempt Certificates, testimonials of education qualification from 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 cancelled without further communication.
A candidate who is employed elsewhere should forward the application through his/her employer and should attach a certificate from the employer that he/she has been permitted to apply for the post in queastion. otherwise the application will not be considered

Place:

Date:

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 may throught E-mail hence kindly recheck your email address.

Signature of Applicant:

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