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GMCH Faculty App Nov12

The document is an application form for a job posting at the Government Medical College & Hospital in Chandigarh, India. It requests information such as the applicant's personal details, educational qualifications, professional experience, references, and a declaration that the information provided is true. The form also includes a certificate section to be completed by the applicant's current employer/cadre controlling authority confirming the details provided and that no disciplinary actions are pending against the applicant.

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64 views1 page

GMCH Faculty App Nov12

The document is an application form for a job posting at the Government Medical College & Hospital in Chandigarh, India. It requests information such as the applicant's personal details, educational qualifications, professional experience, references, and a declaration that the information provided is true. The form also includes a certificate section to be completed by the applicant's current employer/cadre controlling authority confirming the details provided and that no disciplinary actions are pending against the applicant.

Uploaded by

nareshjangra397
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CHANDIGARH ADMINISTRATION DEPARTMENT OF MEDICAL EDUCATION & RESEARCH, GOVT.

MEDICAL COLLEGE & HOSPITAL, CHANDIGARH


Website http://www.gmch.gov.in.

Space for recent passport size photograph

1. 2.

Name of the post applied for Full Name (BLOCK LETTERS)

: :

____________________________________________________ ____________________________________________________ (Surname) (First name) (Second name) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________

3. 4. 5. 6.

Fathers/Husband's name Date of birth (Date/ Month/ Year) with documentary evidence Age (as on the 01.01.2012) Whether working under Central / State Governments / Union Territories /Statutory Bodies / Autonomous Organisations/ Research Institutions Whether permanent/ temporary (with documentary evidence) (a) Permanent Home Address with Telephone/Mobile No.

: : : :

7. 8.

: :

Permanent / Temporary ____________________________________________________ ____________________________________________________

(b) Correspondence/Mailing Address with Telephone/Mobile No. ____________________________________________________ 9. 10. ____________________________________________________ Whether belongs to Gen./ SC / ST / OBC : SC ST OBC (with documentary evidence) Gen. UNDERGRADUDATE/ POSTGRADUATE CARRER (attached attested copies of certificates/degrees in support of your qualifications) Name of the Examination Month & Year of Passing the No. of times Class or Name of the University/ examination attempted Division Institution

11. 12.

13.

Whether postgraduate degree is recognised by Medical Council of India : Yes / No Whether registered with State Medical Register or Indian Medical Register (with documentary evidence) (a) Registration No. with the Medical Council : ___________________________________________ (b) State in which registered : __________________________________________ Teaching/Professional/ Research Experience after obtaining Postgraduate Qualification in chronological order: (attached attested copies of experience certificates) Name of the Date of Date of Total Period Name of the post held (also state Pay Scale and present rate of employer joining relieving whether temporarily or pay and allowances Yrs. Mths Days substantively).

14. 15. 16. 17. the post:-

Additional qualification such as Membership of Scientific Societies etc. : ___________________________________________ Details of Prizes, Medals, Scholarships and National/International awards etc. : ___________________________________________ If selected, what notice would you Required before joining : ___________________________________________ Give below the names/ particulars of two referees from your speciality who are in a position to testify from personal knowledge to our fitness for NAME STATUS ADDRESS

18. 19.

I hereby attach attested copies of certificates / degrees in support of age category, qualification and experience etc. i.e. Date of Birth Certificate, MBBS Certificate, PG Certificate, MCI Registration Certificate for PG, Experience Certificate, Caste Certificate & employer certificate etc. Details of Application Fee paid : Name of the Bank ___________________ Demand Draft No.__________Dated _______ Rs._________

Place : Dated :
DECLARATION BY THE CANDIDATE

(Signature of candidate) ________________________ Government Medical College & Hospital, Chandigarh.

Post applied for

I hereby declare that the above information is true, complete and correct to the best of my knowledge and belief. I have not suppressed any material, fact or factual information. I have never been debarred from appearing at any examination nor have I ever been arrested, prosecuted or convicted by criminal court or involved in any other case registered by the police. I understand that my candidature is liable to be rejected in the event of any mis-statement/ discrepancy in the particulars being detected and after my appointment in such an event, my services are liable to be terminated without any notice to me or reason thereof. I undertake not to make any claim or compensation if at any stage of my selection, my ineligibility for candidature is detected and my candidature is cancelled as a result thereof. Place : Dated : (Signature of candidate)

CERTIFICATE TO BE GIVEN BY THE CADRE CONTROLLING AUTHORITY/ EMPLOYER WHILE FOWARDING THE APPLICATION 1. Certified that Dr./Shri/Smt./Kumari________ holds a post of ________________________________ in this department/office/ institution/ organisation and the particular furnished by the officer are correct as per the record held in this office. I have no objection to his/her application being considered for the post. Certified that no disciplinary/Vigilance proceedings are pending or contemplated against the officer. No major or minor penalty have been imposed to the officer during the last ten years. Name, Signature & Seal of the cadre controlling authority Designation _______________ Office Stamp ______________

2.

No._________________ Dated _______________

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