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21035
Application No # : 1021395

Name of the Post Applying for :

4. Assistant Surgeon (Dental) (General)

Full Name : Nationality / Citizenship : Registration Fee : Payment Mode: Amount : Personal Details : Date of Birth : Gender : Married : Religion : Candidate's Place of Birth : Native District : Father's Name : Father's Place of Birth : Mother's Name : Mother Tongue : Communal Category : Name of the Sub ?Caste : Certificate No : Date Of Issue : Issuing Authority : Taluk : District : Differently Abled Persons : Are you eligible for reservation for the differently abled persons as per the G.O.(Ms) 25, Welfare of Differently Abled Persons Deptt, dated 14.03.2013 : Medical / Dental Council Registration Number : Address for Correspondence :

SRIRAMAN K Indian

Net Banking 700.00

06/04/1987 MALE No Hindu Vellore Chennai Kumaraswamy K Kancheepuram Uma K Tamil Others Brahmin ----NA

No 14945 8/34, Usha Nagar 1st Street Ullagaram

District State : Pin : Permanent Address :

Chennai Tamil Nadu 600091 8/34, Usha Nagar 1st Street

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Ullagaram District State : Pin : Contact Details : Email ID : Mobile No : EDUCATIONAL QUALIFICATION PARTICULARS : Exam Passed S.S.L.C : H.S.C : MBBS / BDS : Specification BDS Year of Passing 2002 2004 2010 Medium of Instruction English English English Whether studied Tamil as one of the subject Yes Yes k.sriraman87@gmail.com 9941918283 Chennai Tamil Nadu 600091

DECLARATION:

I agree to abide by all the conditions specified in the notification / Instruction to the Candidates

I accept the above declaration

Place:

Date: 2013-04-28 10:10:43

Signature of Applicant

Please retain your Application No. and Password emailed to you carefully for further reference