OFFICE USE ONLY

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SI.NO: _________
VECTOR CONTROL RESEARCH CENTRE
(INDIAN COUNCIL OF MEDICAL RESEARCH)
MEDICAL COMPLEX, INDIRA NAGAR
PUDUCHERRY-605 006

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Phone No.0413-2272396, 2272397, Fax No.2272041, Email: vcrc@vsnl.com

Website: (www.vcrc.res.in)
Note: This application form should be filled in by candidate's own handwriting.
All informations must be given in words and not by dashes and dots. No column
should be left blank. Separate applications should be submitted for each post.
Incomplete application will be rejected

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Affix a recent

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Application for the Post of: ____________________
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passport size
photograph
(3.5cm x 4.5cm)

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Demand Draft No. ________________________________ Date ____________________________

Name of Bank _____________________________

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01. Name in Full: Mr./Miss/Mrs./Dr.
(IN CAPITAL LETTERS)

Amount Rs.__________________

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________________________________________________

__________________________________________________
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02. Address: (A) for communication:

__________________________________________________
__________________________________________________

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(B) Permanent:

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__ ______________________________________________
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_________________________________________________

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(C) Telephone /Mobile No:
E-Mail:

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________________________

__________________________

03. Date of Birth ___________________________ 4. Nationality ___________________________

(Proof of certificate duly attested by a Gazetted Officer must be attached)

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Male
Female
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05. Sex:

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(Please the appropriate box)

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2(pto)

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Married

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(Please the appropriate box)

06. Marital status: Unmarried

07. Community : SC
ST
OBC
General
PH
(Please the appropriate box)
(Proof, attach a community certificate duly attested by a Gazetted Officer in support of your claim)

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08. Educational Qualification: (Attach only Attested copies of all certificates by a Gazetted Officer.)
Sl.
No

Examination
Passed

Name of the Board/

University

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1.

SSLC/Matric

2.

HSC

3.

Degree

4.

Year of
passing

Class/
Subject taken
Percentage
of marks
obtained

Regular/Distance
Education

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Diploma /

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PG Diploma

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09. Languages known

Languages
Read only

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Speak only

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Read and Speak

Examination Passed

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10. Previous Service Details: (Chronologically starting from the present employer)

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Name of the Employer

Joining

Date of
Leaving

Post held

No. of
Nature of duties
years
experience

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11. If selected what notice would you require for joining the post: ________________

12. Additional Information, If any

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DECLARATION

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1. I hereby declare that the information furnished above are true to the best of my knowledge and belief.
2. I have informed my Head of Office/Department in writing that I am applying for this post and shall
produce "No objection" certificate at the time of the interview.

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Signature of Candidate
Date:

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Place:

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