ग 2वाहाट All India Institute of Medical Sciences, Guwahati ...

???? ?????? ??????? ????? ?? ?????, ????????

All India Institute of Medical Sciences, Guwahati

Silbharal, Changsari, District- Kamrup

Assam- 781030

??????/No. AIIMS/GUWAHATI/FAC.RECT./2021/3442

????? ?/ Dated : 05-10-2021

OFFLINE APPLICATION

AIIMS Guwahati Faculty- 2021

Online Application Number

(Candidates must ensure applying Online application

before filling this Offline Application)

NOTE

:

1.

TO AVOID ANY MIS-REPRESENTATION OR

INTERPRETATION OF FACTS, THE APPLICATION

MUST BE SENT DULY ¡®TYPED¡¯, SUPPORTED WITH

ATTESTED COPIES OF TESTIMONIALS.

2. BRIEF OF CANDIDATE TO BE SUBMITTED AS PER

ANNEXURE ¨C IV.

PASTE HERE

LATEST

SELF

ATTESTED

PHOTOGRAPH

Application for the Post of :______________________________________________________

at AIIMS, Guwahati

DISCIPLINE

: ______________________________________________

1.

Full Name (BLOCK LETTERS):___________________________________________________

2.

Father¡¯s/Husband¡¯s Name: ________________________________________________________

3.

(a) Mailing Address :_____________________________________________________________

____________________________________________________________________________

______________________________________________________Pin___________________

Fax. No. _____________________ Tel. No. ________________________________________

Aadhaar No.___________________________Mobile No.____________________________

E-mail ID:___________________________________________________________________

____________________________________________________________________________

(b) Permanent Address :___________________________________________________________

____________________________________________________________________________

____________________________________________________Pin_____________________

Tele. No:_________________________ Mobile No:_________________________________

Page 1 of 14

4.

(a) Date of Birth

:

[

]

-------------{Date}

[

]

-------------{Month}

[

]

-----------{Year}

(b) Age

:

(as on last date of

Online application)

[

]

-------------{Years}

[

]

-------------{Months}

[

]

-----------{Days}

(c) Sex

:

Male/Female/Third Gender/Any Other Category

(d) Marital Status

:

Married/Unmarried

5.

Whether belong to PwBD:

Yes or No

(OH-OL & BL)

Percentage of disability : _________________________________________________________

6.

Whether belong to

:

UR

SC

ST

OBC

EWS

(Please strike out which is not applicable) (Attach attested copy of certificate on the proforma)

7.

State of Domicile

: _________________________________________________________

8.

Nationality

: ________________________ Religion: ________________________

9.

a) Registration No. with the Medical Council :_________________________________________

b) State in which registered : _______________________________________________________

10. Educational Qualifications:

(Please attach attested copies of certificates/degrees in support of your qualifications)

(a) Undergraduate Career

Examination Year of

Passed

Passing

Matric/S.S.C.

No. of

attempts

Class/

Division

University/Institution

Intermediate/

HSC

B.Sc.

M.B.B.S/

BDS

Page 2 of 14

(b) Postgraduate Career:

Examination

Passed

M.D./M.S/

MDS

Year of

Passing

No. of

Class/

attempts Division

University/Institution

M.Sc.

D.M/M.Ch.*

D.N.B.

Ph.D.

* Must indicate No. of years of the course (2yrs/3yrs/5yrs) and name of the Institute with full

address.

11. Teaching/Research Experience:

(Please attach attested copies of experience Certificates)

a) Before obtaining Postgraduate/ Super Specialty/Ph.D. Qualification:

Post held

Period

Sl.

(Indicate : Temporary/

No.

From

To

Permanent)

Total Period

Yrs. Mths. Days

Pay Scale

Employer¡¯s

Address

Total

(b) After obtaining Postgraduate/Super Specialty/Ph.D. Qualification:

Sl.

No.

Post held

(Indicate:

Temporary/

Permanent)

Period

From

To

Total period

Yrs. Mths. Days

Pay Scale

Employer¡¯s

Address

Total

Page 3 of 14

12. Details of Prizes, Medals,

Scholarships & National /

International Awards etc.

:

_______________________________________________

13. Additional qualification such as

Membership of Scientific Society

etc.

14. Research Experience, if any,

together with details of published

works in indexed journals.

:

_______________________________________________

: NUMBER OF PAPERS

Accepted for

publication

Published

Presented at

conference

Indexed Non-Indexed

NATIONAL

INTERNATIONAL

Please provide a list of all your scientific publications in chronological order providing details of

articles including whether original article/review/case report, indexed/non-indexed, impact factor

and number of citations for the articles:

Sl.

1

Particulars of Article

Impact Factor

Citations

2

3

4

5

15. Chapter in books/books edited

:_______________________________________________

16. (a) Present employment/post held

:_______________________________________________

(b) Pay Scale

:_______________________________________________

(c) Total emoluments drawn

:_______________________________________________

(d) Complete Address of present

Employer.

:_______________________________________________

Page 4 of 14

17. If Selected, what notice period would

you require before joining

:_______________________________________________

18. Have you been outside India for

Academic Purpose?

If so, give

following information

:__________________________________________________

Country

visited

Dates of Visit

From

To

Duration of Visit

Yrs. Mths. Days

Purpose of visit

19. State the foreign languages you know:

No.

Foreign Language

Can read

Can write

Can speak

(i)

(ii)

(iii)

20. Give below the full details of the names/particulars of two referees from your speciality who are in

a position to testify from personal knowledge to your fitness for the post.

NAME

STATUS

ADDRESS

1.

2.

Note:

i.

You should have worked with one of the referees for at least two years.

ii.

They must not be related to you

21. I attach self-attested copies of certificates/degrees in support of age, category, qualification and

experience etc. as per list enclosed Annexure-II.

22. Self-evaluation of your work, particularly its strengths in different fields of activity including

patient-care, teaching, research and administrative, related to the job, which, in your view, entitles

you to the post applied for may be given in Annexure-III.

Date :

Place:

Signature of the candidate

Page 5 of 14

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