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OFFICE OF THE MAHATMA VIqUR AUTONOMOUS STATE MEDICAL COLLEGE, BIJNOR

APPLICATION FOR THE POST OF NON PG JUNIOR RESIDENT/TUTOR/DBMONSTRATOR

Name of Department................. .......r.......

1. (a) Full Name (Block Letter).......

(b) Age & Sex Paste a Self
Attested
2.
Passport
a
J. Photograph

4. (a) Correspondence address with l'el No.

(b)Permanent address rvith TelNo

6- ;.;.;;;;;;;:;;.;;:;;;;;;;;,;;;;; ;,;;. ;;,;;;;;;;;

1- Registration No. r,vith name of the Medical Coucil ... . ': .....

8- Education QLralification (0,.u.. self attested photocopy of document in support)

Boardflnsti
Year of No. Of
Qualification Year of Passing tution/Univ
Admission Attempts 7o of Marks
ersity

Highschool
MBBS
Other
OLralif-ication
9- (a) Present l3mployment post held since (if
any)''
(b) If yes, address of the present employer and NOC from the
employer.
l0- lnquiry to any or disciplinary action pending/taken during the stLrdl,period at the medical

Note: Errclosed document in supporl of information given on S.No. 3,6,7,8 & 9

DECLAI{ATION BY THE CANDIDATE
I have declare that the above infbrmation is true, and correct to the best of'my knowledge and
belief. lhave not suppresses any material, facts of factual infbrmation. Ihave never been debarred tiom
appearing at any examination. I understand that n-ry candidature is liabte to be rejected in the event of
any mis-statement/discrepancies in the particulars being detected and after my appointment itt such an
event. My services are liable to be terminated rvithollt any notice to me or reason thereof. I underlake not
to make any claim or compensation. If at any stage of my selection, my irleligibility for candidature is
cancelled as a result thereof .

No. of Enclosure:
(Signature of the Candidate)
Name: