APPLICATION FOR THE POSITION OF

Affix Passport size Photograph

Job Ref No.

1. Name of the Applicant: _______________________________________________
   
   
2. Date of Birth: ________________________________________________
   
   
3. Male/Female: _______________ 4. Nationality: ___________________________
   
   

1. Fathers / Husbands Name: ___________________________________________
   
   
2. a. Address for communication: _____________________________________
   
   

b. Permanent Address: ______________________________________

7. a. Telephone No. & Mobile No. : _____________________________________

b. E-mail : ______________________________________

8. Whether belongs to SC/ST/OBC/

Physically Handicapped /Ex-Servicemen (Specify and enclose valid certificate) ______________________________________

9. Have you ever been convicted by a court of law or is there any criminal case/ disciplinary action / vigilance enquiry pending against you? If so specify ______________________________________

Department of Biochemistry

2^nd Floor, JIPMER Academic Center Dhanvantari Nagar Pondicherry-605006 India

Cont.2/

1. Educational Qualifications (Attach attested copies of certificates / mark sheets, etc.)
   
   
2. Details of previous employment/ fellowship (if any)
   
   
3. Research Experience:
   
   
4. Publications:
   
   
5. Any other significant information:
   
   
6. Two Reference Letters:
   
   

Examination Passed	Subject	Year of Passing	Division With %of Marks	Board/ University
10th
12th
B.Sc
M.Sc
NET/ CSIR/ UGC/ICMR
Any other (specify)

Post held	Department/ Institute/company	Permanent/ Temporary/ Contract	Period of employment		Scale of pay	Gross Amount
			From	To

DECLARATION BY THE CANDIDATE: I have gone through the Fellowship Rules and conditions of the award and if selected, I agree to abide by them. The particulars given in the form are correct and I am prepared to present myself for interview at my own expenses, if called upon to do so.

Place:

Date: Signature of the candidate