Academic form a4 (1)
- 1. UNIVERSITY COLLEGE OF MEDICAL SCIENCES (UNIVERSITY OF DELHI) DILSHAD GARDEN, DELHI-11O 095. (Application Form for Academic Posts) POST APPLIED FOR ________________________________________________ DEPARTMENT _____________________________________________________ Advertisement No MC/Estab/2/11/____________date: _______________ Note:- 1. Photocopies of Certificates, degrees, proof of age and mark-sheets etc. should be attached with the application (attested by applicant himself and originals must be produced at the time of joining, if selected) 2. Except where otherwise indicated, applicants appearing for interview shall do so at their own expense. 3. Applicants who are in employment should send their applications through their employer. 4. The Selecting authority may consider the name of any person for appointment, though he may not have applied. 5. Separate application is required for each post applied for. 1. (i) Name( in block letters) : ___________________________________________________________________ (ii) Father's/Husband's Name : _______________________________________________________________ 2. Date of birth _____________ Age/as on (date) _____________ Years ______ Months _______________ 3. Nationality _______________Sex __________________ Married I Unmarried _______________________ 4. (a) Post held, if any, at the time of sending the : ______________________________________________ application with date of appointment (state whether permanent, on probation or temporary) ___________________________________________ (b) Name of Employing Authority : ____________________________________________________________ 5. (a) Present basic monthly pay and allowances (state separately) Pay Band : Rs.__________________ Grade Pay : Rs.__________________ Allowance 1. N.P.A. : Rs.__________________ 2. Traveling : Rs.__________________ 3. House Rent : Rs.__________________ 4. Any other allowance : Rs.__________________ Total emoluments : Rs.__________________ (b) Date of next increment: ___________________________________________________________________ (c) Age of retirement in the present post: ______________________________________________________ 6. Minimum basic pay acceptable Rs. _____________________________ per month. 7. Do you belong to Scheduled Caste / Scheduled Tribe / OBC/ PWD? Yes I No If yes, please attach certificate in support thereof positive. ____________________________________ 8. Address at which a reply to this application, Permanent Address If any, may be sent (IN BLOCK LETTERS) (IN BLOCK LETTERS) ___________________________________________ ________________________________________ ___________________________________________ ________________________________________ ___________________________________________ ________________________________________ PIN CODE NO. : _______________________________ PIN CODE NO.: ________________________ Telephone No. (if any) _________________________ Telephone No. (if any) __________________ Paste passport size photograph be affixed here
- 2. Mobile No. : ___________________________________ Mobile No._____________________________
- 3. 9. Whether the candidate is receiving any pensionary benefits. If so., 'the amount of pension must be indicated ________________________________________________________________________________ 10. Academic Qualifications: (Examinations passed from Matriculation / Higher Secondary onwards to Doctorate/Research degrees). Examination Name of the University Board Year of Passing Attempts in which passed Max. Marks Marks Obtained Percentage of marks obtained Hons Distinction (Position) Hr. Sec. or 10 + 2 Pre-Med / M. Sc. / B.Sc. M.B.B.S. 1st Prof. 2nd Prof. 3rd Prof./ Final * 4th / Final Total Marks of All Professionals Post Graduate (M.D./M.S.) PG. Diploma Degree M.Sc./D.Sc. Ph.D. Total Any other Exam. 11. Academic distinction (e.g. any Prize, Medals, Award etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ * Wherever applicable. Note: 1. Fill each column, where grading instead of marks is awarded, specify the numerical range to each grade. 2. Weightage will not be possible where the information is found incomplete 3. For M.Sc. M.B.B.S. give percentage of marks. Total marks secured in all professional examinations x 100 divided by total (Maximum) marks allotted for all professional examinations.
- 4. 12. Experience (i) Professional including House Job (ii) Teaching I Research Experience. Name of the Institution Designation with pay scale Nature of post: Permanent/ Temporary Class taught Period Total Experience Types of Duties From to 13. Administrative experience. if any. ____________________________________________________________ 14. PUBLICATIONS: Enclose a list of work which is Published or accepted for publication 1, 2 (a) Journals Total :- (i) Indexed Total - (ii) Non-indexed - 1. Main Journal of applicant's Speciality / Society of India Total - 2. Others Total - (b) Books : Name of the book Number of Chapters Edited by Publisher Written by the applicant (c) Reports: WHO UNICEF or other (specify or enclose list) Total - (d) Abstracts: (Enclose list) Total - 1. As Proof of Work, enclose reprints of copy of the 1st page of the published work or letter of acceptance. 2. No. credit will be given for published work unless it is supported by documentary evidence. 3. Indexed: Articles indexed in the Cumulated Index Medicus. Note:- a) Articles should be listed as per pattern used in Cumulated index Medicus. b) No credit will be given if list is incomplete.
- 6. 15. Participation in scientific meeting (enclose list) (a) National or International conferences attended and:- (i) Papers presented by you at National and international conferences: (ii) Papers presented by others in which you are a co-author: (iii) Invited lectures / orations given by you: (iv) CME / Seminars / Workshop attended: (b) Regional Conferences attended and:- (i) Paper presented by you at regional conf: (ii) Papers presented by others in which you a co-author: (iii) Invitation lecture/orations given by you at regional conf.: (iv) CME / Senior / Workshop attended: 16. Name and address of two referees with whom the candidate has worked earlier. 1) ________________________________________ 2) ___________________________________________ _________________________________________ ____________________________________________ 17. Membership of National/International Scientific Bodies. ______________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 18. Extra curricular activities, cultural or other activities _________________________________________ e.g. sports etc.) in which the applicant is interested ___________________________________________ and distinction, if any, obtained in the same. _________________________________________________ 19. Name of post with particulars for which ______________________________________________________ the applicant may have already applied ______________________________________________________ and which have not yet been disposed of. _____________________________________________________ 20. In case of selection, please state the period you would take to join ____________________________ Signature of Applicant DECLARATION: I declare that all the statements made in this application are true to the best of my knowledge and belief. Dated : ____________ Signature of Applicant 21. Forwarded with the remarks that the facts stated in the above application have been verified and found correct and this institution/Organization has no objection to the candidature of the applicant being considered for the post applied for Signature (Head of the Institution/Organization) Designation: ____________________________________________ Pin Code No.: ___________________________________________ Telephone No: __________________________________________
- 7. Dated : ____________ Fax No: _________________________________________________