Icmr Talent Form
Icmr Talent Form
Icmr Talent Form
D PROGRAMME
INDIAN COUNCIL OF MEDICAL RESEARCH
V. RAMALINGASWAMI BHAWAN, ANSARI NAGAR,
POST BOX 4911, NEW DELHI-110029
NB: The application duly filled is to be sent in duplicate to Director General, (Kind Attn: Head
HRD Division) Indian Council of Medical Research, Ansari Nagar, Post Box No. 4911, New
Delhi-110029 Phone- 26588204 (D); 26588980,26588895-Extn:264,Fax: 91-11-26588204,
GENERAL INFORMATION
___________________________________
___________________________________
___________________________________
Permanent address : ___________________________________
___________________________________
___________________________________
___________________________________
Date of Birth : ___________________________________
ACADEMIC RECORD:
List serially, the particulars of all examinations passed from Matriculation/Higher Secondary
onwards and enclose attested copies of certificates/degrees for each of the examinations passed and
mark sheets for Graduate and Post Graduate University examinations passed. Explain gaps in
study, if any, by indicating number of failure, attempts
_
Examination Year of School/ Aggregate Class Distinction Number Topic
passing College/ Division of if
Univ. marks attempts any
obtained
Matric/Higher
Secondary
Pre-
Professional
MBBS
MD/MS
3. PARTICULARS OF RESEARCH
Title of MD/MS-PhD thesis
Name &
Signature of the candidate _____________________________
Name______________________________________________________
Postal address______________________________________________
Telephone_________________________________________________
Fax_______________________________________________________