ALL INDIA INSTITUTE OF MEDICAL SCIENCES

For Office use only (Batch No.)

ANSARI NAGAR, NEW DELHI-110608
APPLICATION FORM
IMPORTANT INSTRUCTION:-1.The size of this application form should not exceed normal photocopy paper (A-4 size). 2. Form to be filled by the candidate in his/her own hand
writing. 3. Use Blue or Black Ball Pen for filling this form. 4. Attested copies of certificates/documentsof Educational/Professional Qualifications/experience etc. to be enclosure with this
form. 5. Tick `√ ’ in the appropriate box against Columns 6, 7, 8 and 10 a). 6. Please read the instruction given in the Advertisement carefully before filling this form. 7. Applications on
other format/size will be rejected.

1. Post applied for Code: (see Advt. for code)

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2. Full name of applicant (in CAPITAL letters)

3. Father’s/Husband’s Name

4. Mother’s name

5. Date of Birth 6. Sex 7. Nationality 8. Category (Tick `√’ in the appropriate box) 9. State of Domicile
Code
D D M M Y Y Y Y Male Female Indian Others SC ST OBC UR

(See Advt. for Code)

10. Whether in Central/State Government service/Autonomous Body/Public Sector Undertaking? (If yes, tick `√’ in the appropriate box)
a) Yes No Regular Temporary/Ad-hoc On Contract b) Date of appointment c) Present position held

D D M M Y Y Y Y
11. Person with Disabilities 12. Details of Educational and Technical Qualification: (Leave box(es) blank if not applicable)
(If yes, tick `√’ in the appropriate box) a) Examination passed: High Hr.Sec/10+2/ Diploma Bachelors Degree PG Diploma Masters Degree PhD
Percentage of School Intermediate in: ……... in……… in:……… in: ……… in:………
OH VH HH Disability (Tick `√’ in the appropriate box)

% b) Year of passing: ----------- ----------- ------------ ------------ ------------ ------------ -------------

c) Aggregate % of
marks secured : ----------- ----------- ------------ ------------ ------------- ------------ ------------
13. Whether Registered with any Council? (If yes, tick `√’ in the appropriate box)
a) Yes No b) Reg. No. c) Date of Registration d) Name of the Council: e) State CODE

D D M M Y Y Y Y ------------------------------------------------- (See Advt. for Code)

14. a) Name & full Mailing Address (in CAPITAL letters only) 15. Candidate’s Photograph 16. Candidate’s Signature :
Name:……………..………………………………….….…. i) Paste here (do not pin or
staple) a recent passport
Address:…………………………..……………………..…. size photo.
…………………………………………………..……….…
ii) The photograph should not
……………………………………….…………………….. exceed this box.

State……………………………. Pin Code: iii) The photograph should

NOT be attested.

b) Permanent Address (in CAPITAL letters only) iv) If the photograph is no t 17. Candidate’s Left Thumb Impression:
Name:……………..………………………………….….…. clear, the application will be
rejected.
Address:…………………………..……………………..….
…………………………………………………..……….…
……………………………………….……………………..
State……………………………. Pin Code:
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
18. Details of Pay Order/ Name of Bank PO/DD No. Date Amount (Rs)
Demand Draft

19. UNDERTAKING: I solemnly affrim that the information furnished above is true and correct in all respect. I have not concealed any information. I realise that if
any information furnished herein is found to be incorrect or untrue, I shall be liable to civil/criminal procecution and also forgo my claim to the appointment in the
Institute. Further my candidature for examination/selection for appointment is liable to be cancelled. I a gree to abide by the Rules and Regulations of the Institute
governing this examination and appointment to the post applied for.

Candidate’s signature
Date: ____________
ATTESTED:
Place: ______________ Signature and seal of attesting
authority (Gazetted Officer)
(SEAL)
RK/EXAMs
 INSTRUCTIONS FOR FILLING THE APPLICATION FORM
1. This Scannable Application Form is to be processed on ICR scanner, therefore get it photocopied/down loaded on an A-4 size
Paper before filling. Fill in the Application Form in your own hand writing, clearly and legibly in BLOCK LETTERS. Do
not overwrite.
2. Fill in the application form from Item No.1 onwards with blue or black ball point pen. Do not write anything in the Columns
meant for “Official use only”.
3. Wherever choice has to be indicated by putting a tick mark [√], take care to put the tick mark prominently and with in the box
only.
4. No document should be attached with this Scannable Application Form. However, copies of certificates/documents such as
educational/professional* qualification, (*registration with concerned Central/State Medical/Dental/Nursing/ Pharmacy/
Technical Council), Registration with Employment Exchange, Working experience in the field applied for, “No Objection
Certificate” if working with Central/State Government (those working with Public Sector Undertaking or with Private Sector
should also submit NOC from their employers), Caste/Community certificate, Handicapped certificate etc. should be submitted
at the time of Interviews.
5. Guidelines to fill in Columns 1 to 16:
Col.1. Post applied for: Write the name of the post you are applying. Also write the CODE No. of th e post as not ified in the
Advertisement.
Col.2. Full name : Write your name in BLOCK LETTERS as given in the records of the Secondary Education Board/University. If
the boxes provided are insufficient, abbreviate your middle name and write your first and last name in full e.g. an applicant
NIKHILESH RANJOMAN CHATTOPADHYAYA should write his name as shown below:
N I K H I L E S H R C H H A P O D H Y AYA
Start writing from the first box itself. Do not write Mrs/Ms/Mr etc. Leave one box blank between two parts of the name.
Col.3 & 4. Father’s and Mother’s name: Same as above.
Col.5. Date of birth: Fill in your date of birth as recorded in Secondary School leaving Certificate or equivalent examination. The
date (e.g. 23rd May, 1985) is to be written as under:

2 3 0 5 1 9 8 5

DD MM Y Y Y Y
Col.6. Sex : If male, tick [√] in the box below ‘Male’. If female, tick [√] in the box below ‘Female’.
Col.7. Nationality : If your nationality is Indian, tick [√] in the box below the word ‘Indian’. If your nationality is other than
Indian, tick [√] in the box below the word ‘Other’.
Col.8. Category: Tick [√] in the appropriate box for the category under which you wish to be considered.
SC-Scheduled Caste, ST-Scheduled Tribe, OBC-Other Backward Classes, UR - Unreserved Category
Col.9. State of Domicile : Write the appropriate Code in the boxes. Code numbers for the various States and the Union Territories
are given hereunder:
Code - States & UTs States/UTs - Code Code - States & UTs
01 - Andhra Pradesh Karnataka - 13 25 - Tamil Nadu
02 - Arunachal Pradesh Kerala - 14 26 - Tripura
03 - Assam Madhya Pradesh - 15 27 - Uttar Pradesh
04 - Bihar Maharashtra - 16 28 - Uttrakhand
05 - Chhattisgarh Manipur - 17 29 - West Bengal
06 - Delhi Meghalaya - 18 30 - Andaman & Nicobar
07 - Gujarat Mizoram - 19 31 - Chandigarh
08 - Goa Nagaland - 20 32 - Dadra & Nagar Haveli
09 - Haryana Orissa - 21 33 - Daman & Diu
10 - Himachal Pradesh Punjab - 22 34 - Lakshadweep
11 - Jammu & Kashmir Rajasthan - 23 35 - Pondicherry
12 - Jharkhand Sikkim - 24

Col.10. Whether in Central/State Government Service: a) If you are employed with Central/State Government, tick [√] in the box
below the word ‘Yes’. If not, tick [√] in the box below the word ‘No’. If you are in service (Regular or Temporary/Ad hoc),
tick [√] in the appropriate box. b) Mention the date of appointment. c) Write in the box the present post/position held.
Col.11. Physically Challenged Candidates: If applicable, tick [√] in the appropriate box for disability with regard to OH,VH,HH.
Also write the percentage (%) of disability in the box.
Col.12 Educational/Professional Qualification: In Col.12 a) Tick `√’ in the appropriate box. In b) write the year of passing the
exam in the space provided and in c) write the aggregate % of marks obtained in the respective examination
Col.13. Registration Number: If you possessed any of the professional qualification and you are registered with any of the Council
(viz. MCI/DCI/State Medical/Dental Council, Indian Nursing Council/State Nursing Coun cil, Central/State Pharmacy
Council, Council for Technical Education or any other Council) which makes you eligible for the post applied for, tick [√] in
the box below ‘YES’ in Col.13 a). If ‘YES’, write the registration number in Col. 13 b). In Col.13 c) write the date, month
and year of registration. In Col . d) write the name of the Council and in Col. 13 e) write the State CODE (for State Codes
please see Col.9 above). If you are not registered with any of the Council, tick [√] in the box below ‘NO’ in Col.13 a) and
write N.A. in Col. 13 b).
Col.14. Name & full Mailing/Permanent Address : Write your name in the first line, full mailing address within the next lines in Col.
14 a) and Permanent Address in Col.14 b), STATE and PIN Code, clearly & legibly, in CAPITAL LETTERS and with in the
space provided because the facsimile of the name and address written by you in this column will be printed on your Admit
Card. Please note that the AIIMS will not be responsible for any delay in or non-receipt of Admit Card caused by failure in
your part to scrupulously follow these instructions.
Col.15. Photograph: Affix firmly a recent high contrast passport size photograph with light background in the space provided for the
purpose. The photo should be pasted (not pinned or stapled). Application without photograph will be rejected.
Col.16. Signature of the candidate : Put full signatures in the space provided for this purpose. The signatures should be clear and
strictly within the box.
Col.17. Leave this space blank for office use.
Col.18. Demand Draft : Write the details such as name of issuing branch, PO/DD No., Date and Amount of Pay Order/Demand Draft
Col.19. UNDERTAKING : You must sign the ‘UNDERTAKING’ and get your signature attested by a Gazetted Officer. Unsigned
application will be rejected.