Imo Esic
 
01 Name (in capital letters)
   
02 Gender Male Female
   
03 State Applied for
   
04 Category you belong to Code of category
   
05 Whether you are PH or Ex. Serviceman
   
   
07 Father's/ Husband's Name (in capital letters)
   
08 Date of Birth Verify my age
   
   
09 Are you a citizen of India BY birth and / or by domicile? By Birth By Domicile
   
10 Permanent Address (in capital letters)
   
11 Pincode
   
12 State
   
13 City
   
14 Contact No
    Check if both are same
   
15 Mailing Address (in capital letters)
   
16 Pincode
   
17 State
   
18 City
   
19 Contact No
   
20 Email Address
   
21 Are you MBBS ? YesNo
   
22 Essential educational qualifications and other training course, if any
 
S.No. Name & Address of College University Duration Degree / Examination Passed Subject Studied Marks %
To From
   
23 Date of completion of compulsory Rotating Internship
   
24 Details of Employment (in chronological order)
 
S.No. Name of the Organization
(please specify whether Central Govt./State Govt./Public Sector /Autonomous
Body/Private Sector 		Position(s) held and to
whom reporting		 Period of Service Nature of Work
done and reasons for leaving		 Scale of Pay Basic Pay & Allowances
   
I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief.

I understand that in the event of any information being found false or incorrect at any stage, my candidature/appointment shall be liable to be cancelled / terminated summarily without notice or any compensation in lieu thereof.

I also affirm that No Objection Certificate from the present employer for applying this post has been applied for/taken.

If selected, I am willing to serve anywhere in India.
   
Place  
Date 10-01-2012