APPLICATION FORM FOR RECRUITMENT OF TEACHING FACULTY ON CONSOLIDATED PAY BASIS IN VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES BALLARI.

1.	 Post applied for	:	
2.	Particulars of the Demand Draft:		

Amount Rs:_________ D.D. No.__________dated_____________

Name of issuing bank & branch:____________________________

Affix self-attested recent passport size photograph here (photograph should be firmly pasted on this page and not stapled.)

3.	Name in full (in block letters)	:			
4.	Father’s / Husband's Name	:			
5.	 Date of Birth	:			
6.	(a) Religion	:			
	(b) Nationality	:			
7.	Gender	:			
8.	Permanent Address	:			
					
9.	Mailing address	:			
10.	(a) e.mail	:			
	(b) Contact Number		Phone:	Mobile:	
11.(i)	(a) If Person With Disability	:	Yes/No________________________	
	(PWD)				
	(b) Percentage of Disability	:			
12.	Community / Category	:			

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13. ESSENTIAL EDUCATIONAL AND PROFESSIONAL QUALIFICATIONS
(Attach annexure, if necessary).
Name & Address of				Degree/		Percentage	
College	University	Duration	Examination		of marks	
		From	to	Passed	Subjects	obtained	

							

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14.	DETAILS OF EMPLOYMENT (IN CHRONOLOGICAL ORDER) (if necessary, attach annexure) 

S. No.	Name & Address of the	Designation	From	To	Total Period	Whether experience	
	Institution					recognized by MCI/DCI	
						(write ‘Yes’ or ‘No’)	
1							
							
2							
							
3							
							
4							
							
5							
							
6							

(Signature of the Candidate)

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DETAILS OF RESEARCH PUBLICATIONS

(PLEASE DO NOT INCLUDE CASE REPORTS & REVIEW ARTICLES)

			Status of			Journal			Remarks		
			Authorship									
												
		Year of								Eligible /		
S.No.	Title of Original Article			Name of the	Indexed		National	Society	International			
		Publication								Not		
												
				Journal	in		Yes / No	Yes / No	Yes / No			
										Eligible		

												

												

SIGNATURE OF THE APPLICANT

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16. Academic achievements and activities ___________________________________ 

(Attach annexure, if necessary). 

17.	List of enclosures: 

(i)	(ii)

(iii)	(iv)

(v)	(vi)

(vii)	(viii)

(ix)	(x)

I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief.

I understand that in the event of any information being found false or incorrect at any stage, my candidature/appointment shall be liable to be cancelled / terminated summarily without notice or any compensation in lieu thereof.

I also affirm that No Objection Certificate from the present employer for applying for this post has been obtained (for central/state government employees).

Place  ___________

Date	___________

Signature of the Candidate