|
|
Basic Details | |||
|---|---|---|---|
| Candidate Id | N/A | Application Date | |
| Applicant's Name | N/A | Registration Number | N/A |
| Father's Name | N/A | Mother's Name | N/A |
| Category as Notice regarding identification of Posts suitable for PWBD see Annexure-III of | 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 | |
| Service End Date | 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 | |
| Till Date | 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 | |
| Till Date | Length of service(In Days) | N/A | |
| Are you Contractual Employee of AIIMS? | N/A | Type Of Institute | N/A |
| Contractual Date Of Appointment From | Contractual Till Date | ||
| Length of service(In Days) | N/A | Marital status | N/A |
| Gender | N/A | Date of Birth | |
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 | |
| 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 | ||||||||||
| City Choice (Stage 1) | |||||||
|---|---|---|---|---|---|---|---|
| # | First Preference | Second Preference | Third Preference | Fourth Preference | |||
| State | |||||||
| City | |||||||
| City Choice (Stage 2) | |||||||
|---|---|---|---|---|---|---|---|
| # | First Preference | Second Preference | Third Preference | Fourth Preference | |||
| State | |||||||
| City | |||||||
| 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 | ||||
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