ANNEXURE-A

(Receipt No)

FORM OF APPLICATION FOR APPOINTMENT IN SKIMS MEDICAL COLLEGE-HOSPITAL BEMINA SRINAGAR Post applied for ______________________ (Reference advertisement Notice No:- dated .. (Serial No) 01. Name of the Candidate (Capital Letters) 02. Fathers/ Husbands Name. (Capital Letters) 03. Permanent Residential Address. 04. Mailing Address.. Contact No.. 05. Date of Birth.. 06. Age as on 01-01-2012. 07. Sex . (Male/Female) 08. Marital Status (Single/ Married/Widow/ Separated) 09. Whether belong to any reserved Category (SC/ ST/ RBA/ Ex-servicemen/ etc.) . (Enclose attested copy of relevant Certificate issued by the competent authority) 10. Whether Physically Handicapped. Yes/No (if yes, Type of disability...................) 11. Academic/ Professional Qualifications as on the date of application: (Attach Attested Photo copies of the . Certificates): Name of the Institution/ Examination Passed Subjects Offered Year of %age of marks Board/ University/ etc. Passing obtained

12. Experience if any, (give details & enclose attested copies of certificates) No. Name of the Institution/ Deptt. Joining Leaving Years

Nature of Job

Declaration: I hereby declare that all statements made in this application are true and correct to the best of my knowledge and belief. In the event of any information being found false or incorrect or ineligibility being detected before or after the selection, I shall be liable for punitive action under rules including termination of service. I have never been arrested, prosecuted or convicted by criminal court or involved in any other case registered by the police. Place... Date. Enclosure
Signature of the Candidate 13. Certificate of Employer (In Respect of In-Service Candidates) . Certified that the information given above has been verified with reference to the personal records of . the candidate. Seal & Signature of the Head of the Department (Acknowledgement) For Office use only: Received an application for the post of .. along with enclosures from Shri/Sht............................. S/O, D/O, W/O. R/O. District Receipt no

Receipt Clerk