aiimsbilaspur.edu.in

1 ALL INDIA INSTITUTE OF MEDICAT SCIENCES,BILASPUR,( ).lrR{o qrrfiq .itrgtrETT {iR{Fr, Rorsgr, ( CELLA dvertisement PhotoName of the postapplied forPERSONAL DETATLS (rN cAprTAL LETTERSIl. F'ull Name2. Father,s Name3. Address forCorrespondencewith PIN codenumber4. PermanentAddress wlthPIN codenumber5. E-mail ID (inBLOCKLETTERS)6. Phone/Cell No.+917. AlternateNumber+915tDetails of EducationalExamination passedUnlverslty I Institution/Council of ExamlnationSecondary (1 Ott ) council registration number,PROFESSIONAL EXPERIENCE (IN CHRONOLOGICAL ORDER)(Enclose a separate sheet dulg authenficolted bg gour slgnahtre, tf the spo,cebelout is >ut is lnsufficientSl thePostheldPayLevelNature ofEmplovmentPeriodAdhoc/Temporary/Perman ent/DeputationFrom(DD/MM/WITo(DD/MM/YY)E 11. State towhich youbelonENature of Duties performed during above perlod17.))))}}}

2 PubllcationsTotalIn Indexed NatlonalJournalsIn Indexed IuternationalJournals:-, distinction/ prize Paper presentation selected, what notice period would you require beforejoining:..2 1' Self-evaluation of your work, particularly its strengths in different fields of activityincluding patient care, teaching, research and administrative, related to the job,which, in your view, entitles you to the post applied for may be given in have attached self attested copies of degrees in support of age, category,qualification and experience etc. as per list enclosed , :Place:Signature of the candidateE]ANNEXURE IDECLARATION BY THE CANDIDATEPost applied forat AIIMS, Bllaspur ( )I' hereby declare that the above information is true, complete and correct to the best ofmy knowledge and belief' I have not suppressed any material, fact or factualinformation' I understand that my candidature is liable to be rejected in the event ofany mis-statement/discrepancy in the particulars being detected and after myappointment in such an event; my services are liable to be terminated without anynotice to me or reasons thereof.

3 I am not aware of any circumstance, which mightimpair my fitness for employment under the :Place:Signature of the INDIA INSTITUTE OF scIENcEs, BILASPUR, PRADESHPost applied forSELF EVALUATION(Required under Column 2l of the application):1 Date:Signature of ( Re qu ire " H:I"t ilHlr":r',XHpp r ic ati o n;(a) Identity Proof (PAN card, Passport, Driving License, voter card, Aadhar cardetc.)(b) certihcate showing Date of Birth (10tr' Mark sheet/ passport/ Birth certificate).(c) sc/sr/oBC/pwBb certificate i.*.a ;;;;;"*t authority (if applicable)(d) Four recent passport size photographs.(e) Class loth & tZttr Uart< sireet and Certificates.(f) Qualifying degreei, B. Mark sheet and degree certificatesii. Any other qualification/certificate(g) Registratio., *itr, Nursing council of India/State Nursing council(h) Experience Certificate(i) No objection certificate from the present employer in case a candidate isworking in nldy etc.)

4 +0). Proof of publications/ Awards/ Medals/ Training undergone(k) Undertaking that the candidai" has not been coivicted by court of law andthere are no criminal proceedings pending against the candidut" leNrvnxuneIV)# To be produced latest by date of appearing in interviewTHE DULY FILLED FORM HAS TO BE POSTED/DEPOSITED WITH?_"_!lay Director (Administration),AIIMS-Bilaspur ' solemnly declare that I am not convicted in any criminalcase and there are no criminar proceedings pending against me in any court of ,hereby acknowledge that if I submit or produce any falsedocument and it is discovered subsequently then I shall be liable under the ApplicableLaw for the time being in : The above statements have been made by me voluntarily which are trueto the best of knowledge and :Place:Signature of the candidateECheck listName of of the cadre controlling Authority/Autho : Applications without forwarding through proper channer, vigilanceclearance and complete CR Dossiers will not be apprication forwarded through proper channel/ Nocattached?

5 Whether attested copies of the up-to-date ApARs for rast 05(Iive) years attached?whether Vigilance clearance certifi cate attached?Whether Integrity Certifi cate attached?Statement of Minor /Major penaJties imposed (if any) attached?E