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8 views

Self Attested Photo

Uploaded by

gajendrasinghjnv007
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Office of the Principal, Autonomous State Medical College

Piprola, Shahjahanpur, Uttar Pradesh, Pin-242001


Email: [email protected] Website: www.smcshah.in
Application Format

Advertisement Number and Date: ……………………………………………………………

Post Applied …………………………………. Department…………………………………... Self Attested


Photo

Note:- All information must be completed by the applicant.

1. Name of Applicant …………………………………………………………………………………


2. Gender (Male/Female)..……………………………………….……………………………………
3. Father/Husband’s Name (Including Surname) ………………………..……………………………
4. Present Address of Residence (including PIN code) ………….……………………………………
…………………………………………………………………………………….………………
Name of the City ……………………….…….…….. Phone No. ……………….…………………
Mobile Number ……………………………………. Email. ID …………………………………..
5. Permanent Address …………………………………………………………………………………
………………………………………………………………………………………………………
Name of the City ………………………………….. Phone No. …………………………..………
Mobile Number ……………………………… .…. Email. ID ..…………………………………..
6. Aadhar Card Number ………………………………………………………………………………
7. PAN Card Number …………………………………………………………………………………

8. Date of Birth (enclose the mark sheet of high school examination) …………………………….…
9. Age of applicant as on 01-07-2022 ……..………. Day …….….…… Month ....................... Year.
10. Applicant’s Marital Status- Married/Unmarried …………………………………………………..
10. Date of Marriage ……………………………………………………………………………………
11. Category: Unreserved / Scheduled Caste / Scheduled Tribes / Other Backward Classes / EWS /
Disabled …………………………………………………………………………………
(Attach photocopy of certificate issued by competent authority for reserved category)
12. Registration Number and Name of the Medical Council and Date ……………………………......
a- MBBS-
b- MD/MS-
c- MCH/DM-
13. Educational Qualification: (Enclose attested photo copies of certificates and marks sheets)

No. Name of the Institution/ Year Subject Marks Obtained/ MBBS Total Number of
Examination Board/ University Max Marks Marks/ attempt (s)
Percentage
1 MBBS

2 MD/MS

3 MD/MCH
14. Educational Experience:-

No. Designation From To Duration Institution Name Recognized


by MCI

1 Professor

2 Associate Professor

3 Assistant Professor

4 S.R./Tutor/Demonstrator

(Attach experience certificate)

15. Research Publications:-

Research Publications as per Vancouver


No. Designation Number
reference style

1 Professor

2 Associate Professor

3 Assistant Professor

4 S.R./Tutor/Demonstrator

(Attach Photo Copy, only 1st Page & Maximum 10 Pages)

16. Application Fee Demand Draft No. ……………………… Dated ……………………. Bank Name
…………………………………….. for Rs. 500/- in favor of Principal, Autonomous State Medical College,
Shahjahanpur. Payable at Shahjahanpur-242001 is attached in original.
17. List of attached certificates ………………………………………………………………………..

// Announcement //

1. I certify that the above information given by me is complete and true. In the event of information being false
my application form/appointment letter can be cancelled.
2. I certify that I have not been found guilty by any court of any offense of moral decimation nor is there any
such case against me in any jurisdiction.

Place …………………………………..

Date ………………………………….. Signature of the Applicant

……………………………

Full Name
CHECKLIST

S.
Particulars Yes / No
No.
1 Two Passport size recent color Photographs
2 Please bring Interview Letter at the time of Interview
3 Matriculation/High School certificate from a recognized Board of Education/University
in support of your Date of Birth as claimed by you in your application
4 Mark Sheets of all the passing Examinations.
5 Attempt certificate for MBBS Course by Competent authority.
6 Degree Certificate of MBBS or equivalent as per NMC norms.
7 Registration Certificate of MBBS from NMC/State Medical Council
8 Attempt Certificate for MD/MS or equivalent Course (as per NMC) by Competent
Authority.
9 Degree Certificate of MD/MS or equivalent as per NMC norms.
10 Registration Certificate of MD/MS or equivalent from NMC/State Medical Council
11 Documentary evidence(s) supporting that the Degree concerned is from Institute(s)
recognized by NMC.
12 Cast Certificate if belonging to SC/ST/OBC category etc. from the competent authority in
support of the category claim along with Domicile Certificate from the State of Uttar
Pradesh not below the rank of DM. in case of SC/ST/OBC category etc. (and in case of
female candidates on behalf of father only). The cast Certificate issued within six months
should be submitted.
13 Post MS/MD teaching experience as Senior Resident/Faculty, mentioning the period of
experience (Including Joining and Relieving dates) from the competent
authority/Employer.
14 Original Research articles- documentary evidence of Indexing as per NMC norms.
15 No Objection Certificate from the present employer for this interview.
16 Aadhar Card
17 PAN Card

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