APPLICATION FORMAT

Application For Specialist or General Duty Doctor

To,
The Medical Director,
L.N.M Railway Hospital,
N.E. Railway – Gorakhpur (U.P.)
PIN – 273012

01. Name (In Hindi) ..........................................................

(In English) ........................................................
02. Father/Husband’s Name (In Hindi) ........................................................
(In English) .....................................................
03. Date Of Birth (In Figure) ........................ (InWords) ..........................................
04. Category to which HE/SHE belongs to(put tick mark): (UR/SC/ST/OBC)
05. Nationality .............................
06. Are you an Ex-Railways employee or have worked in Railways as CMP (if yes, give details)
07. Educational/Professional Qualification :
Examination Year Of Passing Medical No. Of Attempts % of marks
college/University
High
School/Equivalent
Intermediate/Equivale
nt
MBBS Part- I
MBBS Part- II
MBBS Part- III
Aggregate % in
MBBS/PG

09. Registration Number Of Medical Council ........................... State ........................

10. Attested Documents required along with the original are as under :

A: Two recent Passport size photo.

B: Certificate Indicating the Date Of Birth (High School/Equivalent Certificate).
C: MBBS Degree with Marks sheet (All Parts) of Recognized Institution.
D: P.G. Degree/Diploma Mark Sheet and Certificate.
E:House Job certificate If any.
F: Certificate to support of caste of ST/SC/OBC
G: Medical Council Certificate.
H: Professional/Teaching experience certificate.

I hereby declare that all the statement made in the application are true, complete and correct to the best
of my knowledge and belief. I understand that in the event of any particulars or information given herein, if found false
or incorrect or cancelled the fact even in any mis-statement and or discrepancy in the particulars, contract will liable to
be terminated and any CIVIL/CRIMINAL legal action can be taken against me for this . I understand the I am not
eligible for any TA/DA for this interview.

Signature Of Candidate
Place .............................
Date ...............................
Full name ..................................................
Address .....................................................
....................................................