All India Institute of Medical Sciences

All India Institute Of Medical Sciences, New Delhi Ansari Nagar, New Delhi - 110029 Application Form

Basic Details
Candidate Id	N/A	Application Date	N/A
Applicant's Name	N/A	Registration Number	N/A
Father's Name	N/A	Mother's Name	N/A
PWBD	N/A	Which facility do you require to appeare in the exam?	N/A
PWBD Percentage	N/A	PWBD Category	N/A
PWBD Sub Category	N/A	Category	N/A
Category Certficate Issue date	N/A	I do not have valid OBC certificate of the given date	N/A
Issue date of Acknowledgement Slip for renewal of category certificate	N/A	Nationality	N/A
State of Domicile	N/A	Are you a Ex-serviceman/Commissioned Officer(including ECO,SSCO)	N/A
Service Provided in (Name of Armed forces)	N/A	Service Start Date	N/A
Service End Date	N/A	Length of service(In Days)	N/A
Are you currently employee of ESIC (Employees' State Insurance Corporation) Hospital?	N/A	Type Of Job Status	N/A
Present Position Held	N/A	Date Of Appointment From	N/A
Till Date	N/A	Length of service(In Days)	N/A
Are You Regular Govt. Servant?	N/A	Name of Institution/Organisation	N/A
Type Of Organisation	N/A	Type Of Job Status	N/A
Present Position Held	N/A	Date Of Appointment From	N/A
Till Date	N/A	Length of service(In Days)	N/A
Do you want to claim age relaxation as a Govt. employee as per advertisement?	N/A	Are you Contractual Employee of AIIMS?	N/A
Type Of Institute	N/A	Contractual Date Of Appointment From	N/A
Contractual Till Date	N/A	Length of service(In Days)	N/A
Marital status	N/A	Gender	N/A
Date of Birth	N/A

Contact Details
Phone Number	E-mail id	Postal Address	Permanent Address
N/A	N/A	, , , , .	, , , , .

Payment Details
Mode	Date	Transaction id	Amount
N/A	N/A	N/A	N/A

ID Proof
Id Proof	Id Proof Number
N/A	N/A

Qualification Details
Qualifying Exam	Institute Name	University Name	Date of Passing
N/A	N/A	N/A

Medical Registration Details:
Registered as	Registration No:(Nurse)	Registration No: (Midwife)	State Name of Nursing Council	Issuing Date of Registration
N/A	N/A	N/A	N/A	N/A

Experience Details
S. Number	Organisation Name	Hospital / Institute Name	Position Held	Employee Type	Number of beds in Hospital	Currently Working	Start Date	End Date	Nature Of Duties	Length of service(In Days)
No Experience

State Choice (Stage 1)
#	First Preference	Second Preference	Third Preference	Fourth Preference
State

State Choice (Stage 2)
#	First Preference	Second Preference	Third Preference	Fourth Preference
State

Certificates
No Objection Certificate	Not Uploaded	Category Certificate	Not Uploaded
PWBD Certificate	Not Uploaded	PWBD Appendix A-1/A-2/A-3 Certificate	Not Uploaded
Upload NCL certificate (if NCL & OBC certificate are same kindly upload same certificate)	Not Uploaded	Upload Certificate for Claiming Age Concession (Appendix D)	Not Uploaded

UNDERTAKING/DECLARATION: I hereby declare that the information furnished by me in the Registration/Application Form is correct and nothing has been concealed. In case any information furnished by me is found to be false/incorrect/untrue than i shall be liable to civil/criminal prosecution and my claim to admission/appointment/registration/ service in the Institute may be cancelled/terminated.

Signature of Candidate

Thumb of Candidate

All India Institute Of Medical Sciences, New Delhi

Application Form