Tele: “JIPMER" Website: www.jipmer.edu.in Phone: 0413 - 2272380-2272389 Fax: 0413 – 2272067- 2272735 JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION & RESEARCH Dhanwantari Nagar, Puducherry 605 006 (Institution of National Importance under Ministry of Health & Family welfare) In continuation of this office Advertisement in Employment news dated _________ for filling up the post of __________________________________ on deputation basis, the eligible officer may be applied for the same by using this format placed below:APPLICATION FOR THE POST OF _____________________________________ ON DEPUTATION BASIS AT JIPMER, PONDICHERRY-6 1. Name and Present Designation ( in Block Letters): Affix recent photo attested by Self 2. Date of initial appointment with the pay scale. : 3. Present Scale of pay 4. Full Address ( in Block letters) : 5. Date of Birth (in Christian era) : 6. Date of retirement under Central/State Government Rules: 7. Educational Qualifications : 8. Whether educational and other qualifications required for the post are satisfied. (if any qualification has been treated as equivalent to the one prescribed in the rules, state the authority for the same.) Qualifications/Experience required Qualifications/Experience possessed by the Officer 9. Please state clearly whether in the light of entries made by you above, you meet the requirements of the post. 10. Details of Employment in chronological order. Enclose a separate sheet duly authenticated by your signature if the space below insufficient Service Particulars: Sl.No. Name & Address of the Institution/ Organization Name of the post held & the Scale of pay Whether Regular/ Period Adhoc/ From To Nature of duties 11. In case the present employment is held on deputation/contract basis, please state: a. The date of initial appointment b. Period of appointment on deputation/contract. c. Name of the parent office/organization to which you belong. 12. Additional details about present employment. a. Central Government c. Autonomous Organisation e. Universities. Please state whether working under: b. State Government d. Government Undertakings f. Research Institute 13. Are you in revised scale of pay? If yes, give the date from which the revision took place and also indicate the prerevised scale. : Page 1 of 2 14. Total emoluments per month now drawn. : 15. Additional information, if any, which you would like to mention in support of your suitability for the post. Enclose a separate sheet if the space is insufficient: 16. Whether belongs to SC/ST/OBC : 17. Any other relevant information : DECLARATION I hereby declare that all the statements made in this application are true, correct and complete to the best of my knowledge and belief. In the event of any information being found false/incorrect or ineligibility being detected before or after interview or selection, my candidature/appointment is liable to be rejected/terminated. Place: Date : Signature of the Candidate Page 2 of 2