codewith

Correspondence PIN for 3. PERSONAL

Permanent
Address 4. Address Father's
Name 2. Name
Full1. Advertisement
Name
applied for
only) Name
Resident
(Senior
code
with
PIN
Transaction
details
Bank of of
ITO0YDEXIO the the
DETAILS Post
Department No.
(Post ALL
(IN Code) INDIA
CAPITAL
ASH INSTITUTE
STHI A
AN| LETTERS) DOUmab SRI2/7|o6
LIAS
RECRUITMENTCELL OF
i2]2|2024 MEDICAL
Date
SCIENCES

K
A BILASPUR,
B MA
A P (H.P.)
HP TA
igo -
MmU Amount

A|ND|| Appendix-l
 SH A
5. E-mail ID
(in BLOCK LETTERS)
A

+ 1
6.Phone/Cell No. 2 692 33
1
7. Alternate Number 9914 0 S
S 33

8. Marital Status Married Unmarried Other

D D MM Y 10. Nationality INDIAN

9. Date of Birth

26 0 11, State to which

youbelong Je

UR EWS OBC (NC) SC ST

12. Category of the
Candidate
(Please tick only)

UR EWS OBC (NC) SC

13. Category of the ST
Post Applied
(Please tick only)

Type of Handicap Percentage of Disability

14. If Physically Challenged Candidate

15. Details of Educational Qualifications

Month & No. of

Examination Passed Universityl Board/ Institution/ Councilof Year of Extra
Examination
passing Attempts

Secondary (10h) CBSE Isr

 Senior Secondary (12"") |(st
MBBS
Rquns, KARNATAIA 2014 lst

M.D./M.S./DNB J Amu uNNERSIny 202)

Any Other

16. DETAILS OF EMPLOYMENT IN CHRONOLOGICAL ORDER STARTING WITH THE LATEST

(Enclose aseparate sheet duly authenticated by your signature, if the space below is
insufficient)
Nature of Period
Employment
Name
S. No.
Organization of the Pay Adhocl
Institution Post Level To
held Temporary/ From
Permanent (DDIMMYY) (DD/MM/Y)
Deputation

spaah Manch
DUmtdbgot
1.
Pemret a023 2024
isptalShunla
Nature of Duties performed during above period

2.
June 022Apul2023
Nature of Duties performed during above period

OPD, megeney and geal

SMVBU, Juy 0l6 ct 016

3.

Nature of Duties performed during above period

17. Publications
In Indexed International
In Indexed National Journals Journals
Total

before joining
18. If selected, what notice period would you require
activity including patient care,
work, particularly its strengths in different fields of
19. Self-evaluation of your entitles you to the post applied
teaching,research and administrative, related to the job, which, in your view,
for may be given in Annexure- I. Dedcahd hardwog
support of age, category, qualification
and
20. Iattach attested copies of certificates/ degrees
experience etc. as per list enclosed Annexure-ll.

Date: hayofane
candidate s ma
riace: Signature ofthe
DECLARATION BY THE CANDIDATE
at AllMS, Bilaspur (H.P.) I, hereby
Post applied for J m r l d t
declare that the above information is true, complete and correct to the best of my knowledge and belief. I
have not suppressed any material, fact or factual information. I understand that my candidature is liatble to be
rejected in the event of any mis- statement/discrepancy in the particulars being detected and after my
appointment in such an event; my services are liable to be terminated without any notice to me or reasons

thereof. Iam not aware of any circumstance, which might impair my fitness for employment under the
Government.

Date:
Pamate
Place: Signature of the candidate
Shumla
ANNEXURE-I
ALL INDIA INSTITUTE OF MEDICAL SCIENCES, BILASPUR, HIMACHAL PRADESH
Post applied for Jems leent
SELF EVALUATION
(Required under Column 18 of the application)

Date:
Signature of candidate
 ANNEXURE-I|
LIST OF ENCLOSURES
(Require under Column 19 of the application)
(a) ldentity Proof (PAN Card, Passport, Driving License, Voter Card, Aadhar Card etc.) (b)
Address Proof
(C)Certificate showing Date of Birth (10h Mark sheet/ Passport/ Birth Certificate). (d)
Four recent passport size photographs.
(e) Class 10th &12th Marksheet and Certificates.
() Qualifying degree
i. MBBS Marksheet and degree certificates
i, MD/DNB/MS Marksheet and degree certificate
ii. DM/M. Ch/DNB Marksheet anddegree certificate
(g) Attempt and Internship Certificate.
(h) Registration with Medical Council of India/State Medical Council
) Experience Certificate
) FMGE certificate conducted by NBE (For foreign graduate)
(k) No Objection Certificate from the present employer in case a candidate is working in
Govt./SemiGovt./Autonomous Body etc.#
() Proof of publicationsl Awards/ Medals/ Training undergone
(m) Undertaking that the candidate has not beenconvicted by court of law and there are no criminal
proceedings pending against the candidate (ANNEXURE II)
#To be produced latest by date of appearing in interview

ANNEXURE- II|

UNDERTAKING
. Shalya lanaele solemnly declare that Iam not convicted in any criminal case and there
are no criminal proceedings pending against me in any Court of Law.
hereby acknowledge that if Isubmit or produce any false document
and it is discovered subsequently then I shal be liable under the Applicable Law for the time being in
force.

Declaration: The above statements have been made by me voluntarily which are true to the best of

knowledge and belief.

Date: 13|12/202
Place: ShayaPandute
Signature of the candidate