COLLEGE OF MEDICINE & J. N. M. HOSPITAL, WEST BENGAL UNIVERSITY OF HEALTH SCIENCES

Application Form

Please fill - up the form correctly, after submission of the form, you will be given only 1 chance to edit any mistakes.

Application Form

Application for the post of

Particulars of the Candidate

Name in Full (in BLOCK letters)

Parent’s / Guardian’s Name

Date of Birth

[DD – MM – YYYY]

Nationality: ‘INDIAN’

Yes
No

Sex

Male
Female

Caste/Category

General
Scheduled Caste
Scheduled Tribe
Physically Challenged

Religion

Mailing Address

Address

Police Station

District

State

Pin Code

Telephone No. with STD Code

Mobile No

E-Mail ID

Permanent Address

Village/ City

Police Station

District

State

Pin Code

Telephone No. with STD Code

Educational Qualification

Sl. No.	Examination Passed	Year	Board / University	Total marks obtained Division / Class	% of Marks
example		numbers only in yyyy format		numbers only	numbers only
1.
2.
3.
4.
5.
6.

Computer Education

Certificate / Course	Name of the Institute	Passing Year
		yyyy

Experience

Name and Designation of the two referees

Name	Designation	Organisation	Address	Telephone Number

Extra Curricular Activities

Any other relevant information with reference to the requirement of the post

Bank Draft particulars

Name of the Bank

Branch

Draft No

SC/ST candidates write N/A here

Date

Declaration of the Candidate

(a) It is declared that each statement and/or contents of this declaration and /or documents, certificates submitted along with the declaration form, by the undersigned are absolutely true, correct and authentic. In the event of any statement made in this declaration subsequently turning out to be incorrect or false the undersigned has understood and accepted that such misdeclaration in respect to any content of this declaration shall also be treated as a gross misconduct thereby rendering the undersigned liable for necessary disciplinary action.

Yes
No

(b) I have informed my employer in writing that I am applying for this post.

Yes
No

Sl.
No.

Designation

Name of the Institution

Name of the Employer

Cause of leaving the job, if any