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    Application - Format CIL

    Uploaded by

    catalyst1986
    This document appears to be an application form for a medical position. It requests information such as name, date of birth, addresses, education history, professional qualifications, training experience, current position, and a declaration signed by the applicant. Supporting documents such as certificates for date of birth, caste, education/professional qualifications, internship, registration, experience and bank payment receipt must be provided. The format requests information in sections including personal details, education history, post-graduation details if applicable, training, experience, declaration and list of enclosures.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Application - Format CIL

    Uploaded by

    catalyst1986
    79 views3 pages
    This document appears to be an application form for a medical position. It requests information such as name, date of birth, addresses, education history, professional qualifications, training experience, current position, and a declaration signed by the applicant. Supporting documents such as certificates for date of birth, caste, education/professional qualifications, internship, registration, experience and bank payment receipt must be provided. The format requests information in sections including personal details, education history, post-graduation details if applicable, training, experience, declaration and list of enclosures.

    Original Description:

    Coal India Application

    Original Title

    Application_Format CIL

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    © Attribution Non-Commercial (BY-NC)

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    This document appears to be an application form for a medical position. It requests information such as name, date of birth, addresses, education history, professional qualifications, training experience, current position, and a declaration signed by the applicant. Supporting documents such as certificates for date of birth, caste, education/professional qualifications, internship, registration, experience and bank payment receipt must be provided. The format requests information in sections including personal details, education history, post-graduation details if applicable, training, experience, declaration and list of enclosures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    79 views3 pages

    Application - Format CIL

    Uploaded by

    catalyst1986
    This document appears to be an application form for a medical position. It requests information such as name, date of birth, addresses, education history, professional qualifications, training experience, current position, and a declaration signed by the applicant. Supporting documents such as certificates for date of birth, caste, education/professional qualifications, internship, registration, experience and bank payment receipt must be provided. The format requests information in sections including personal details, education history, post-graduation details if applicable, training, experience, declaration and list of enclosures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    APPLICATION

    FORMAT
    Affix recent Passport size Photograph self attested

    (All entries should be in Capital Letter) 1 Application for the post of : Grade : (In case of Sr. Medical Specialist/Medical Specialist , specialty should be mentioned)/ Sr. Medical Officer ) 2 Name of Applicant(in Block Letters) :

    3 4

    Father / Husband Name : Marital Status :


    D D M M Y Y Y Y

    Male/Female :

    Date of Birth (in figure):

    Date of Birth(In words) : ------------------------------------------------------------- ----------------(Attach Matriculation Certificate) Age as on 1st May, 2013 : _________________________________ 6. Address for communication : --------- ---------------------------------------------------------------------------------(with PIN Code) --------- ----------------------------------------------------------------------------------------- --------- ----------------------------------------------------------------------PIN Code : Telephone No : Mobile No : E_mail ID : (should be active for one year) Fax No.:

    7. Permanent Address: ---------------------------------------------------------------------------------------(with PIN Code) ------------------ ---------------------------------------------------------------------------------------------------------------------------------PIN Code : 8 9 Religion : Caste : GEN/SC/ST/OBC(Non-creamy layer) : (Enclose Valid caste certificate issued by the Competent Authority)

    10. Physically Handicapped (40% or more Disability): (Enclose Certificate issued by the Competent Authority) 11. (a) Registration No.. Date enclosed)

    .% of Disability

    (Medical Registration Certificate to be

    (b) Date of completion of Internship: .. .from(Instt./Hospital___________________ (Certificate to be enclosed) 12 (a)Educational Qualification: Name of the Name of the Course University/School High School/ Matriculation/ SSC Exam. HSC /12th Std 12(b) Professional Qualification:-

    Year of passing

    % age of Marks

    MBBS
    Name of Instt./Univ. Year of Passing 1st yr. 2nd yr. 3rd yr. 4th yr. Total Marks Overall Percentage of Marks PG Degree/ Diploma (Specialty to be mentioned) 1st yr. 2nd yr. 3rd yr. Total Marks If the candidate obtains MBBS from Foreign University/Institute : MBBS Year of Total % of Country Name of passing Marks/Grade Marks Univ./Institute 1st yr. 2nd yr. 3rd yr. 4th yr. Total Marks Total Marks Marks Obtained % of Marks Overall percentage No.of Attempt

    Overall percentage

    No.of Attempt

    In case marks obtained in grade/grade point etc. is awarded instead of marks, a certificate from the Registrar of University /Head of the Institute is to be submitted regarding specific equivalent percentage. Kindly ensure that overall percentage of marks is mentioned

    After passing MBBS from foreign university, the date of Passing qualifying examination from MCI, India _________________________ and certificate from MCI to be enclosed.

    13. Whether undergone any specialized Training (If so, Please indicate the details)
    Name of the Organization Period of Training From To Total Period Nature of Training Remarks

    14. Experience after completion of Internship (as on 01.05.2013) (if any):


    Sl. No. Post held With nature of duties Grade Pay Scale Name of the Organization Period From/To Total Period Yr. Month. Reason of Leaving

    15.

    Challan No.

    Date

    SBI (Branch Address)

    DECLARATION:
    I,------------------------------------------------------------------------, do hereby declare that the information as furnished above is correct to the best of my knowledge and belief. If any of the information as furnished is found to be incorrect, my candidature for the post applied for, is liable to be cancelled.

    Signature of the candidate


    Date: List of Enclosures: 1. Matriculation certificate in support of date of birth 2. Valid Caste Certificate for SC/ST/OBC(NCL) and PH (complete address of the Issuing Authority should be mentioned. Certificate should be as per proforma prescribed by Govt.of India for the purpose of appointment 3. Certificate of educational / professional qualification along with mark-sheets of all the years, date of publication of result & percentage of marks (Incase marks is given in Grade Point, the same should be converted into percentage duly certified by the Institute /University 4 Attempt Certificate 5 Internship Certificate 6 Registration Certificate issued by Medical Council of India /State Medical Council 7 Experience Certificate -date of joining & date of completion should be clearly mentioned 8 Candidates having PG Degree /Diploma are required to submit a certificate issued by MCI / State Medical Council to the effect that the course is recognized by Medical Council of India / State medical Council 9 Copy of the Bank Challan Note : (i) If space is inadequate for Sl. No.12 & 13, use separate sheet (ii) Candidate is advised to his/her signature on each page of application Form and also all enclosures

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