Annexure

अखिल भारतीय आयुर्वि्ሺान सं्ቝान, मदु रै

ALL INDIA INSTITUTE OF MEDICAL SCIENCES, MADURAI
An Institute of National Importance under PMSSY Division, Ministry of Health and Family Welfare
Government of India

ANNEXURE - I
APPLICATION FORM FOR THE POST OF JUNIOR RESIDENT (NON-ACADEMIC)
Personal Details (in Block Letters)

Please attach
recent passport
size photograph

1. Full Name

2. Father’s /
Husband’s name

3. Address for
Correspondence

4. Permanent
Address

5. E-mail Id (In
capital letters)
6. Phone/Cell No.1
Phone/Cell No.2
Land Line No.

7. Date of Birth D D M M Y Y Y Y 8. Nationality

(Please attach 9. Name of the State to
document for which you belong
evidence)

10. Gender (Male / Female/others)

11. Category of the UR/OBC/SC/ST/EWS

Candidate (√)
1 2. If Physically Challenged (PwBD
Category) Percentage Disability

1 3. Details of Educational Qualifications:

Total
University/Board/Instit Month, Marks
Examination ution Year of Secure Percent No. of Extra
Passed / Council of Passing d age Attempts
examination
Total
Marks
Secondary (10th)

Senior
Secondary(12th)
MBBS

Others(.......................)

Others(.......................)

Others(.......................)

14. Details of previous experience including as Junior Resident in AIIMS or outside: -

Name of FROM TO Nature Total Reason

Designat of Monthly for
the D D M M Y Y D D M M Y Y ion Duties Emolum leaving
Organiza
tion Perform ents Service
ed s

1 5. Please bring original certificates along with 1 set of self attested photocopies of
related documents at the time of interview.

1 6. Details of Application Fee:

Demand draft – Number & Bank:

Date :
Amount Rs:
 DECLARATION

I hereby declare that entries made in this form as above are true and correct to the
best of my knowledge and belief. In the event of any information being found
false/incorrect candidature/ services are liable to be terminated without any notice. I
agree to abide by the terms and conditions of appointment.

Declaration:
I, Dr……………………………………. S/o/ D/o do hereby declare and affirm that all the
statements made in this application are true, complete and correct to the best of my
knowledge and belief and nothing has been concealed thereon. In the event of any
information being found false or incorrect or ineligibility detected at any point of time, my
candidature shall be liable to be rejected without any notice. I further declare that I fulfil
all the conditions of eligibility regarding age limit, educational qualification and
experience etc. prescribed for the post. I agree to abide by the terms and conditions of
appointment. I am not employed in any Government Institution/ Autonomous body. OR
I am employed with Government Institution/Autonomous body and if selected, I shall
join duty only after acceptance of my resignation from my current employer.

Signature of the Candidate

 For office use only

Comments of the screening committee:

1. Eligible/Ineligible:
2. If ineligible the reasons thereof (Mark tick): Age
Educational Qualification
Incomplete Application
Non submission of fee
Others
3. Submission of candidate’s category certificate:
OBC Candidate: Candidates must attach certificate valid for the posts under the
Central Government of India which mentions that the Candidate does not belong to
Creamy Layer. The vacancies are being advertised in financial year 2023-2024, therefore,
valid NCL-OBC certificate issued during the period from 01.04.2023 to 31.03.2024 will be
considered valid.
4. Remarks, if any:

Name of the Screening Committee Member:

Signature of the Screening Committee Member:

 ANNEXURE - II

CHECK LIST FOR THE POST OF JUNIOR RESIDENT ( NON- ACADEMIC)

(Put a cross (X) wherever applicable)

Sr. No. Copy of the documents (self -attested) Please tick

01 Certificate for Date of Birth (Class X or XII Certificate)

02 MBBS Mark Sheets (All Semester)

03 MBBS Degree

04 Internship completion certificate

05 Attempt certificates

06 MCI/NMC/ State Medical council registration

SC/ST/OBC/PwBD certificate issued by the competent authority

07
(if applicable)

08 Experience (if any)

09 No Objection Certificate (if any)

10 Copies of any other relevant documents

11 FMGE

12 Address Proof Certificate

13 Identity Proof Certificate

14 Photos

15 Mention attempts for MBBS:

i) 1st Year

ii) 2nd Year

iii) 3rd Year

iv) 4th Year

Signature of the Candidate

Date:
 ANNEXURE - III

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR

APPOINTMENT TO POST UNDER THE GOVERNMENT OF INDIA
This is to certify that Shri / Smt. / Kum*. son /
daughter of shri ………………………………………of village / town… .............................................. in
District ……………….. in ………………...............…...… state belongs to community which is
recognized as a backward class under :-
(1) Resolution No.12011/68/93-BCC© dated 10th September 1993, published in the
Gazette of India - Extraordinary - part 1, Section 1, No.186 dated 13th September 1993.
(2) Resolution No.12011/9/94-BCC dated 19th October 1994, published in the Gazette of
India - Extraordinary - part 1, Section 1, No.163, dated 20th October 1994.
(3) Resolution No.12011/7/95-BCC, dated 24th May, 1995, published in Gazette of
India - Extraordinary - part 1, Section 1, No.88, dated 25th May 1995.
(4) Resolution No.12011/44/96-BCC, dated 6th December 1996, published in Gazette of
India - Extraordinary - part 1, Section 1, No.210, dated 11th December 1996.
(5) Resolution No.12011/68/93-BCC, published in Gazette of India - Extraordinary -
No.129, dated the 8th July 1997.
(6) Resolution No.12011/12/96-BCC, published in Gazette of India - Extraordinary -
No.164, dated the 1st Sept 1997.
(7) Resolution No.12011/99/94-BCC, published in Gazette of India - Extraordinary -
No.236, dated the 11th Dec 1997.
(8) Resolution No.12011/13/97-BCC, published in Gazette of India - Extraordinary -
No.239, dated the 3rd Dec 1997.
(9) Resolution No.12011/12/96-BCC, published in Gazette of India - Extraordinary -
No.166, dated the 3rd Aug 1998.
(10) Resolution No.12011/68/93-BCC, published in Gazette of India - Extraordinary -
No.171, dated the 6th Aug 1998.
(11) Resolution No.12011/68/98-BCC, published in Gazette of India - Extraordinary -
No.241, dated the 27th Oct 1999.
(12) Resolution No.12011/88/98-BCC, published in Gazette of India - Extraordinary -
No.270, dated the 6th Dec 1999.
(13) Resolution No.12011/36/99-BCC, published in Gazette of India - Extraordinary -
No.71, dated the 4th April 2000.
Shri/Smt./Kum* ........................................................................... and/or his/her family ordinarily reside(s)
in the….……….…….District of the ………………….… State. This is also to certify that he/she does not belong
to the persons/ sections (Creamy Layer) mentioned in column 3 (of the Schedule to the Government of India,
Department of Personnel & Training OM NO.36012/22/93 - Estt (SCT), dated 08.09.1993) and modified vide
Government of India, Department of Personnel and training O.M No.36033/3/2004-Estt.(Res) dated
09.03.2004.
Place :....................... Signature
Dated : ..................... District Magistrate/Dy. Commissioner etc.

*Strike out whichever is not applicable (With seal of office)

NB: (a) The term 'ordinarily' used here will have the same meaning as in section 20 ofthe Representation of
People’s Act., 1950.

The Authorities competent to issue OBC caste certificates are indicated below:-
(i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner /Additional
Deputy Commissioner / Deputy Collector / 1st class Stipendiary Magistrate / Sub - Divisional
Magistrate
/ Taluk Magistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank
of 1st class Stipendiary Magistrate).
(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate/ Presidency Magistrate.
(iii) Revenue Officer not below the rank of Tahsildar, and
(iv) Sub-Divisional Officer of the area where the Candidate and or his family resides.
 ANNEXURE - IV

DECLARATION TO BE SIGNED BY NON-CREAMY LAYER OBC CANDIDATES ONLY

I son/daughter Shri
resident of Village/ Town/ City/ District State
(certificate enclosed) hereby declare that I belong to the community which is recognized as a
backward class by the Govt. of India for the purpose of reservation in services as per orders contained in
Department of Personnel and Training Office Memorandum No.36012/22/93-Estt(SCT) dated 8.9.1993.

It is also declared that I do not belong to the persons/sections (creamy layer) mentioned in Column
3 of OM No. 36012/22/93-Estt(SCT) dated 08.09.1993 and modified vide Govt. of India, Department of
Personnel and Training OM No.36033/3/2004-Estt(Res) dated 09.03.2004.

Place:
(Signature of applicant)
Date: (in running handwriting)
 ANNEXURE - V
FORM OF SC/ST CERTIFICATE PRESCRIBED
Form of certificate as prescribed in M.H.A., O.M., No.42/21/49-N.G.S. dated the 28.1.1952, as revised in
Dept.of Per. & A.R. letter No.36012/6/76-Est. (S.C.T.), dated the 29.10.1977, to be produced by candidate
belongingto a Scheduled Caste or a Scheduled Tribe in support of his/her claim.

This is to certify that Shri./Smt./Kum.*………………………… son/daughter* of ..........................of

……………….. village/town* .................................... in district/Division* of the State/Union Territory* belongs to
the ...................................... Caste/Tribe which is recognised as a Scheduled Caste/Scheduled Tribe* under:

The Constitution (Scheduled Caste) Order,

1950 The Constitution (Scheduled Tribe)
Order, 1950
The Constitution (Scheduled Caste) (Union Territories) Order,
1951 The Constitution (Scheduled Tribe) (Union Territories)
Order, 1951

(as amended by the Scheduled Caste and Scheduled Tribes Lists (Modification) Order, 1956, the Bombay
Re-organization Act, 1960, the Punjab Re-organization Act, 1966, the State of Himachal Pradesh Act, 1970
the North Eastern Areas (Re-organization) Act, 1971 and the Scheduled Castes and Scheduled Tribes Orders
(Amendment) Act, 1976).

The Constitution (Jammu and Kashmir) Scheduled Caste Order, 1956.

The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order,
1959. The Constitution (Dadra and Nagar Haveli) Scheduled Caste Order,
1962.
The Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order,
1962. The Constitution (Puducherry) Scheduled Caste Order, 1964.
The Constitution (Uttar Pradesh) (Scheduled Tribes) Order,
1967. The Constitution (Goa, Daman & Diu) Scheduled Caste
order, 1968. The Constitution (Goa, Daman & Diu) Scheduled
Tribes Order, 1968. The Constitution (Nagaland) Scheduled
Tribes Order, 1970.
The Constitution (Sikkim) Scheduled Caste Order,
1978. The Constitution (Sikkim) Scheduled Tribes
Order, 1978. The Constitution (Puducherry) Scheduled
Tribes Order,2016
1. Applicable in the case of Scheduled Caste/Schedule Tribe persons who have migrated from one
State/Union Territory Administration:

This certificate is issued on the basis of the Scheduled Caste/Scheduled Tribe certificate issued to
Shri/Smt*……………………………… father/mother of Shri/Smt/Kum*… ........................... of village/town* in
District/Division* …………………..………. of the State/Union Territory* ……………………….. who belongs to
the caste/tribe which is recognised as a Scheduled Caste/Scheduled Tribe* in the State/Union
Territory*
……………………….. issued by the (name of prescribed authority) vide their No .......................date
…………………... Shri*/Smt*/Kum*… ............................. and/or his/her* family ordinary reside(s) in village/
town*…………………. of the State/Union Territory of …………………….

Signature ……………………
Place ……………………….. **Designation ………..........……
Date ………………………. (With seal of Office) State/Union Territory

* Please delete the words which are not applicable.

Please quote specific Presidential Order. Delete the paragraph which is not applicable. Should be signed by
the Authorities empowered to issue Scheduled Caste/Scheduled Tribe certificates as specified above.
 ANNEXURE - VI

Government of ...............
(Name & Address of the authority issuing the certificate)

INCOME & ASSEST CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER SECTIONS

Certificate No. VALID FOR THE YEAR

Certificate No. VALID FOR THE YEAR

This is to certify that Shri/Smt./Kumari

son/daughter/wife
of permanent resident of
,
Village/Street Post Office
, District in the State/ Union Territory
Pin Code Whose photograph is attested below belongs to Economically
Weaker Sections, since the gross annual income* of his/her “family‟** is below Rs. 8 Lakh (Rupees
Eight Lakh only) for the financial year
His/ her family does not own or possess anyof the following assets ***
I. 5 acres of agricultural land and above;
II. Residential flat of 1000 sq. ft. and above;
III. Residential plot of 100 sq. Yards and above in notified municipalities;
IV. Residential plot of 200 sq. Yards and above in areas other than the notified
municipalities.

Shri/Smt./Kumari belongs to
the
caste which is not recognized as a Scheduled Caste, Scheduled Tribe and
Other Backward Classes (Central List).

Signature with seal of Office Name

Designation

Recent Passport size attested photograph of the applicant

Recent
Passport size
attested
photograph of
the applicant

* Note 1: Income covered all sources i.e. salary, agriculture, business, profession etc.
**Note 2: The term “Family‟ for this purpose include the person, who seeks benefit of reservation, his/
her parents and siblings below the age of 18 years as also his/her spouseand children below the age of
18 years.
***Note 3: The property held by a “Family” in different locations or different places/cities have been
clubbed while applying the land or property holding test to determine EWS status.
 ANNEXURE - VII

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL

Affix here recent
Certificate No. attested
Photograph
Date: showing the
disability duly
DISABILITY CERTIFICATE attested by the
chairperson of the
Medical Board
This is certified that Shri/Smt/Kum……………………………………………………..
son/wife/daughter of Shri…………………………………………………of………… age………….
sex………………………………..identification mark(s) is suffering from permanent disability of following
category :-

A Locomotors or cerebral palsy:

(i) BL-Both legs affected but not arms.

(ii) BA-Both arms affected (a) Impaired reach

(b) Weakness of grip

(iii) BLA-Both legs and both arms affected

(iv) OL-One leg affected (right or left) (a) Impaired reach
(b) Weakness of grip
(c) Ataxic

(v) OA-One arm affected (a) Impaired reach

(b) Weakness of grip
(c) Ataxic
(vi) BH-Stiff back and hips(Cannot sit or stoop)
(vii) MW-Muscular weakness and limited physical endurance
B Blindness or Low Vision: (i) B- Blind
(ii) PB- Partially Blind
C Hearing impairment: (i) D- Deaf
(ii) PD- Partially Deaf
(DELETE THE CATEGORY WHICHEVER IS NOTAPPLICABLE)

This condition is progressive/non-progressive/likely to improve/not likely to improve. Re-assessment of

is case is not recommended/is recommended after a period of years months.*

Percentage of disability in his/her case is………………….percent.

Sh./Smt./Kum…………………………………………………meets the following physical requirements for

discharge of his/her duties:-

(i) F-can perform work by manipulating with fingers. Yes /No

(ii) PP-can perform work by pulling and pushing Yes /No
(iii) L-can perform work by lifting Yes /No
(iv) KC-perform work by kneeling and crouching Yes /No
(v) B-can perform work by bending Yes /No
(vi) S-can perform work by sitting Yes /No
(vii) ST-can perform work by standing Yes /No
(viii) W-can perform work by walking Yes /No
(ix) SE-can perform work by seeing. Yes /No
(x) H-can perform work by hearing/speaking Yes /No
(xi) RW-can perform work by reading and writing. Yes /No

Signature and seal of the Medical Authority.

I ANNEXURE - VIII

SELF-DECLARATION

I, Dr. S/o D/o

appearing for written test/interview for the post of Junior Resident (Non- Academic) on tenure Basis (for a
period of 12 months) for AIIMS, Madurai held on _____________________ do hereby declare that I have not been
worked as Junior Resident (Non- Academic) for a period of one year on Regular/ Ad-hoc / Contract Basis in
any of the Central / State / semi Govt. / Autonomous Organizations. I have worked as Junior Resident (Non-
Academic) on Regular / Ad- hoc / Contract Basis for the period from to at
which is a Central / State / Semi Govt. / Autonomous Organizations.

I understand that if the said information as given by me is proved to be false, I will liable to be terminated from
the services.
Signature :

Name:
 ANNEXURE - IX

CERTIFICATE / NO OBJECTION BY THE PRESENT EMPLOYER

(In case candidate is in Govt. / Semi Govt. / PSU/ Autonomous Body service etc.)

No. Date

Certified that Dr. holds a post of for the period from

to on regular / adhoc / contract basis in this Department /Office / Institution /
Organization. The Institute has no objection to his/her application being considered for the post of JUNIOR
RESIDENT (Non- Academic) at All India Institute of Medical Sciences, Madurai (for a period of 12 months).
In the event of his / her selection to the post, he/she will be relieved from the duty to take
up the post of
in All India Institute of Medical Sciences, Madurai.

Signature

Designation

(Seal with Name & Designation)

Office Stamp