vf[ky Hkkjrh; vk;qfoZKku laLFkku

ALL INDIA INSTITUTE OF MEDICAL SCIENCES

lkdsr uxj Hkksiky ¼e/;izns’k½ & 462020
Saket Nagar, Bhopal (M.P.) – 462020

Lafonk vk/kkj ij xSj&ladk; in gsrq vkosnu izi=&2019

Application form for Non-faculty Post on Contractual Basis - 2019

foKkiu@fnukad la- Affix Passport

Advt. No: Admin/AIIMS/Bhopal/Rect.Cell/2019/02 dated 01/02/2019 Size self –
Advertisement No.
attested recent
& Date colour
photograph
vkosfnr in@ with white
Post applied for background
here
1- uke Li"V v{kjksa esa Name in block letters :-

2- firk@ifr dk uke Li"V v{kjksa es@

a Father/ Husband's Name in block letters :-

3- ¼v½ LFkk;h irk@ (a) Permanent Address :-

jkT;@ State

fiu@ Pin
¼c½ Mkd dk irk@ (b) Postal Address:-

jkT;@ State

fiu@ Pin
AIIMS BHOPAL Page 1 of 4
 4- laidZ fooj.k @ Contact Details :-
,l-Vh-Mh- dksM lfgr Qksu ua-@
Phone No. with STD Code

eksckbZy ua-@ Mobile No.

bZ&esy@ E-Mail

5- izek.k i= ds vuqlkj tUefrfFk fnu@DD ekg@MM o"kZ@Year

Date of Birth as per the certificate

आवेदन के अंतिम तदन ंक में आयु

Age as on last date of application i.e.
15.02.2019

6- fyax@Gender : iq:"k@Male efgyk@Female

¼laacaf/kr ij fpUg yxk,a@Tick the relevant.)

7- D;k vki vtk@vttk@vfio ls lacaf/kr gS

¼gka@ugha½
Are you a SC/ST/OBC Candidate? (Yes/No)

;fn gka- rks oxZ dk mYys[k djsa ¼izek.k&i= layXu djs½a vfio dh n'kk esa Hkkjr
ljdkj ds rgr vkjf{kr inksa ij fu;qfDr ds fy, vHkh gky esa oS/k mi;qDr izkf/kdkjh
}kjk tkjh izek.k&i= gksuk pkfg,A
If yes, mention the Category (attach relevant Supporting document. In case of OBC, the
certificate should be issued by the appropriate authority recently valid for appointment to
the post reserved under Govt. of India

8- क्या आप/Are You By Birth By Domicile

(अ) जन्म से भारतीय नागररक हैं अथवा अधिवास द्वारा (सम्बंधित पर धिधन्हत करें )
(a) A citizen of India by birth or by domicile?

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 9- fodykaxrk&(Yes/No)
Person with disability (PWD)/
;fn gkW rks izfr’kr dk mYys[k djsa
If yes, then mention the %

10- 'kS{kf.kd ;ksX;rk@ Educational Qualification :-

ijh{kk dk fo"k;@fo|k@ fo'ofo|ky;@ ikB~;Øe dks vafre ijh{kk izkIrkad@ ikB~;Øe fVIi.kh@
uke@ fof'k"Vrk@ laLFkku@ iw.kZ djus dh mrhZa.k djus dk Marks dh Remark
Name of Subject/ egkfo|ky;@ frfFk@ Date ekg rFkk o"kZ@ obtained vof/k@
the discipline University/ of Month & Duration
Examina- /Specialty Institute/ completion Year of of
tion College of course Passing Course
final
examination

11- अनुभव/Experience

Ñi;k lacfa /kr mikf/k;ksa dksa fpfUgr djs@

a Please tick the relevant Degrees

laxBu dk uke @ lsok xzg.k lsok NksM+us /kkfjr in dqy vuqHko D;k vki dk;Z dh iz—fr is&cSaM ,oa ewy osru
¼ljdkjh@xSj djus dh dh dk uke @ Total rnFkZ@lafonk@ ¼f'k{k.k] 'kks/k ;k
lfgr
ljdkjh@ rkjh[k @ rkjh[k@ Name of Experiance fu;fer vk/kkj jksxh Pay Band
Lok;RR; laLFkk ½ Date of Date of the post ij mipkj½ and
Name of the joining leaving gS@Whether @Nature present
Organization on Adhoc/ of work basic pay
(Government/ Contract/ (Teaching,
Private/ Regular Research or
Automomous) Basis patient care)

AIIMS BHOPAL Page 3 of 4

 fuEufyf[kr izek.k&i=ksa@vfHkys[kksa dh Loizekf.kr izfrfyfi;ka uhps fn, gq, Øe esa lyaXu djsa%/Attach
self-attested photocopies of the following certificate/documents in the order as mentioned below :

I. tUefrfFk ls lacaf/kr izek.k i=@Certificate of date of birth.

II. bl vkosnu izi= ds Ø- 10 esa mYysf[kr 'kSf{kd ;ksX;rk dh mikf/k izek.k&i=@Degree
certificates of the qualifications as mentioned in Sl. No.10 of this application form.
III. vuqHko izek.k&i=@ Experience Certificates

12- क्या आप फार्मेसी एक्ट 1948 के तहत पंजीकृत हैं/ ((हााँ/नह ं)

Are you registered pharmacist under pharmacy act 1948 (Yes/No)

[के वल फामााधसस्ट ग्रेड II एवं धडस्पेंससंग अटेंडेंट के आवेदकों के धलए/only for the applicants of Pharmacist Grade-
II and Dispensing Attendants]

13- क्या आपके पास एल.एर्म.वी एवं एच.एर्म.वी व्यावसाययक लाइसेंस है / (हााँ/नह ं)
Do you have LMV and HMV Commercial License? (Yes/No)

[के वल ड्राईवर (सािारण ग्रेड) के आवेदकों के धलए/only for the applicants of Driver (Ordinary Grade)]

14- vU; dksbZ lwpuk%

Any other information:

15- 'kqYd fooj.k/Fees Details

DD. No._________________Amount (in Rs.) ________________Dated______________
Bank Name _____________________________________________________________

16- vlayXudksa dh dqy la[;k%

Total number of enclosures:
opu c)@UNDERTAKING
eSa lR; fu"Bk ls vfHkiqf"V djrk@djrh gw¡ fd Åij nh xbZ lwpuk] tgka rd eq>s irk gS] lR; rFkk lHkh
rjg ls lgh gSA eSus fdlh Hkh lwpuk dks ugha Nqik;k gSA eSa opu nsrk@nsrh gw¡ fd blesa nh xbZ dksbZ
lwpuk ;fn xyr ;k >wBh ik;h tkrh gS] rks eSa ykxw fu;eksa ds vuqlkj dh xbZ dkjZokbZ ds fy, mRrjnk;h
gksÅaxk@gksÅ
a xhA
I solemnly affirm that the information furnished above is true and correct in all
respects to the best of my knowledge. I have not concealed any information.
I undertake that any information furnished herein is found to be incorrect or false, I
shall be liable for action as per rules in force.

LFkku@Place

mEehnokj ds gLrk{kj@ Signature of the Candidate

fnukad@Date

mEehnokj dk uke@ Name of the Candidate

¼Li"V v{kjksa esa@ In block letters)
*******
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