CONFIDENTIAL TATA MEDICAL CENTER, KOLKATA
14 MAR (EW), New Town, Kolkata 700 160
www.tmckolkata.com
Telephone: 91-33-66057000
TMC application form for Fellowship
Position applied for
Affix recent
passport size
Medical Council Registration No. State Date photograph
Updated Registration No. ---------------------- State ----------------- Date------------------
PERSONAL DATA
Name: Dr
Present Address
City State Pin
Telephone Mobile
Permanent Address
City State Pin
Telephone Mobile
Email
Date of Birth_____________ Age: _______________ Gender: Male Female Others
Father’s Name & Occupation _____________________________________
Spouse’s Name & Occupation ________________________________________
Mother Tongue Other Languages Spoken
Nationality Religion
PAN No : AADHAR :
EDUCATIONAL QUALIFICATIONS
Degree Specialty Exam Passout Institution/ Marks Division/ No. of
Month Month College/ Obtained Class Attempts
& Year & Year University
Matriculation
(10th Standard)
10+2 Standard
MBBS
Diploma if Any
MD/MS/DNB or
Equivalent
Explain breaks if any:
Compulsory Rotating Internship (For MBBS)
Date Started: Date Completed:
Done in College/Hospital: University:
TRAINING DETAILS
Program Duration Year Organized by
EMPLOYMENT EXPERIENCE (Start from present employment)
Name and address of Period Position held Location Reasons for
organization From To leaving /
break
TEACHING EXPERIENCE, IF ANY :-
Date
Appointment Subject Institution/ College University
From To
Assistant Professor
Lecturer
Demonstrator or Senior
Resident
Junior Resident
Research Fellow
Post-Doctoral Fellowship
Any other
PUBLICATIONS AND RESEARCH WORK (State only the numbers)
Type of Publication Number of published Number of publications
or accepted as first author or
corresponding author
Original Research Papers in Indexed Journals
Other publications in Indexed Journals
Research Papers in Non-Indexed Journals
Text Books or Monographs or Thesis
Chapters in Text Books or Monographs
Abstracts in Indexed Journals
Unpublished abstracts presented at conferences
AWARDS / FELLOWSHIPS
MEMBERSHIP OF PROFESSIONAL BODIES.
Reviewer or Member of Editorial Board of Indexed Journals or peer-review committees of
national bodies, institutions, etc.
Service: Contributions towards setting up of new unit/ specialty/ service/ laboratory/programs/ or
Therapeutic/ diagnostic procedures developed or patents obtained (enclose supporting documents).
Contributions in community or national programs.
Describe (in 150 words) your most notable contribution in service/ teaching or research.
REFERENCES
Please provide the names, professional designations, business relationship and full mailing addresses, of three
references. Referees should have a good knowledge of your competencies, and must be familiar with your
work. One reference should be the current and immediate supervisor.
Name
Designation Work relationship
Address E-mail
Telephone (with STD / ISD code) Mobile
Name
Designation Work relationship
Address E-mail
Telephone (with STD / ISD code) (mobile)
Name
Designation Work relationship
Address E-mail
Telephone (with STD / ISD code) (mobile)
Current monthly gross salary and Annual CTC: Rs.
Notice required for joining the position, if recruited
Tentative Date of Joining
GENERAL INFORMATION
1. Are any of your relatives employed by Tata Medical Centre? Yes No
If yes, specify Name Relation
2. Have you ever applied/have been interviewed at TMC before? Yes No
If yes, please specify details
I hereby testify that the information provided by me in this application form is true and correct to the best of my
knowledge and belief. I accept that if any information is subsequently found to be false, I will be liable for immediate
disqualification or dismissal from service without any notice or liability occurring to the organization.
Date
Place: Signature of the Applicant
List of documents attached to application
1. MBBS Certificate [ ] YES [ ] NO
2. MD/MS/DNB Certificate [ ] YES [ ] NO
3. MD/MS/DNB Pass out documents [ ] YES [ ] NO
4. DM/MCh / DNB Super specialty Certificate [ ] YES [ ] NO
5. DM / MCh / DNB super specialty pass out doc [ ] YES [ ] NO
6. Medical Council Registration Certificate [ ] YES [ ] NO
7. Experience Certificate: [ ] YES [ ] NO
8. PAN /ADHAR/ passport / Voter ID card [ ] YES [ ] NO
9. Any Other Certificates [ ] YES [ ] NO
FOR OFFICE USE ONLY
To be engaged from: Grade: Basic:
Function: Designation: Division:
Location: Induction Status: Trainee Probationer
Signature of the Head-Human Resources: ________________________
