Indira Gandhi Medical College & Research Institute
(Government of Puducherry Institution) Vazhudavur Road, Kathirkamam, Puducherry – 605 009 Telephone : 0413‐2277542 & 2277545 ‐ FAX: 0413‐2277289 Email: [email protected] No.151‐3/IGMC&RI/Estt./Rectt.‐Paramed/2014 Puducherry, dated: 19/11/2014 RECRUITMENT DETAILS
Applications are invited from the eligible Indian Citizens who are Natives/Residents of Union Territory of
Puducherry for Direct Recruitment to the following posts:
(A)
MODE OF APPLYING FOR THE FOLLOWING 5 CATEGORIES OF POSTS ARE THROUGH “ONLINE”
ONLYby way of official website: https://recruitment.puducherry.gov.in, which is available from 10.00 A.M. on
20/11/2014 to 5.00 P.M. on 09/12/2014.
3
4
08
09
Physiotherapist
PB-2-Rs.
9300-34800
Grade Pay
4200
PB-2-Rs.
930034800+
Grade Pay
4200
Pharmacist
PB-2-Rs.
930034800+
Grade Pay
4200
Technician
PB-1Rs.520020200+
Grade Pay
2800
10
6
16
66
Educational qualification
Essential:
Master's Degree in
Psychology/
Sociology/Social Work from a
recognized Institution
Desirable:
Two years experience as a
MSW
in a recognized hospital
Essential:
Bachelor Degree in
Physiotherapy
Desirable:
One year experience in the
field
of rehabilitation
Essential:
1. Bachelor's Degree in
Pharmacyfrom a recognized
institution/University or
equivalent
2. Registered as Pharmacist
underthe Pharmacist Act,
1948.
Essential:
1. B.Sc. MLT (three years
course)from a recognized
institution/University
2. Computer knowledge
Desirable:
Two years experience in
Medical Lab in a recognized
Hospital.
Age
limit
Distribution of
Marks for selection
Reservation
Vertical
Horizontal
Not exceeding
35 years
03
Medical Social
Worker/
Psychiatry Social
Worker/
Vocational
Counsellor
No.
of
posts
to be
filled
Basic (Degree)-50
PG-40
Desirable-experi-10
EE seniority-15
GEN-7
OBC-1
MBC-1
SC-1
ExSM-1
Not exceeding
35 years
2
01
Name of post
Scale of
Pay / Pay
Band
Basic (HSC)-50
Degree-40
Desirable-experi-10
EE seniority-15
GEN-5
MBC-1
Not exceeding
32 years
1
Post
Code
No.
Not exceeding
35 years
Sl.
No
Basic (HSC)-50
Degree with Regn.50
EE seniority-15
Basic (HSC)-50
Degree with
Comp.know--40
Desirable-experi-10
EE seniority-15
GEN-11
SC-2
MBC-2
OBC-1
EXSM-2
MSP-1
GEN-36
OBC-7
SC-10
MBC-11
EBC-1
BCM-1
EXSM-7
DAP-2
MSP-3
1 12
PB-1Rs.520020200+
Grade Pay
2800
32
Not exceeding
32 years
5
Radiographic
Technician
including Dark
Room Asst.
Essential:
Degree in Radiography from a
recognized institute
(or)
HSC or equivalent with
Diploma
in Radiography with one year
experience as Radiographic
Technician in a recognized
Hospital
(or)
HSC or equivalent with
Certificate in Radiological
Assistant course with two
years experience as
RadiographicTechnician in a
recognized Hospital
Basic (HSC/SSLC)50
Degree/HSC with
Diploma
&experi/HSC with
Certifi-50
EE seniority-15
GEN-19
SC-5
MBC-5
OBC-3
EXSM-3
DAP-1
MSP-2
LAST DATE FOR RECEIPT OF“ONLINE” APPLICATIONSUNDER (A) CATEGORY: (Online application
available in the website from 10.00 A.M. on 20/11/2014 to 5.00 P.M. on 09/12/2014)
Online generated application should besubmittedalong with the attested photo copies of the requisite testimonials
by “Registered Post with Acknowledgement Due” (or) “in person “dulysuperscribing on the cover as
“APPLICATION FOR RECRUITMENT TO THE POST OF …………………………” (specify the name of the post),
so as to reach “The Director, Indira Gandhi Medical College & Research Institute, Vazhudavur Road,
Kathirkamam, Puducherry-605 009” on or before 19/12/2014 at 5.00 P.M.
(B)
MODE OF APPLYING FOR THE FOLLOWING 13 CATEGORIES OF POSTS ARE ONLY BY POST OR
IN PERSONby way of downloading the ApplicationForm available in the website: www.igmcri.com
02
Statistician
PB-2-Rs.
930034800+
Grade Pay
4200
No.
of
posts
to be
filled
2
Educational qualification
Age
limit
Distribution of
Marks for selection
Reservation
Vertical
Essential:
1. Master's Degree in Statistics
2. Familiarity with standard
Electronic Statistical Software
Desirable:
Experience in Health statistics
for two years
Basic (Degree)-50
PG with stat.
software-40
Desirable-experi-10
EE seniority-15
Horizo
ntal
GEN-2
1
Name of post
Scale of
Pay / Pay
Band
Not exceeding
35 years
Sl.
No
Post
Code
No.
2 Refractionist /
Optometrist
PB-1Rs.520020200+
2800 GP
3
1
Basic (HSC/SSLC)50
Degree/Diploma with
experi. &
Tamil Know-50
EE seniority-15
Basic (SSLC)-50
HSC/Diploma with
experience--40
Desirable-Degree--10
EE seniority-15
GEN-2
GEN-2
Essential:
1. H.Sc. or equivalent
2. Diploma in
Refractionistcoursewith two
years experience as a
Refractionist in a recognized
Hospital
Desirable:
B.Sc. Optometry
Basic (HSC)-50
Degree & Diploma
with experi-40
Desirable-PG-10
EE seniority-15
GEN-3
Essential:
1. Degree in speech pathology
from a recognized University
(or) equivalent qualification in
relevant field
(or)
Diploma in speech pathology
withtwoyears experience in the
relevant field in a recognized
hospital/institution
2. Knowledge of Tamil
Basic (HSC/SSLC)50
Degree/Diploma
with experi-50
EE seniority-15
GEN-3
PB-2-Rs.
930034800+
Grade Pay
4200
3
Essential:
1. Bachelor Degree in Botany/
Zoology/Home
Science/Nutrition/
Chemistry/Social Science/Social
Anthropology (10+2+3 system)
from a recognized University or
its equivalent
2. Diploma in Health Education
from a recognized University
3. One year experience in the
relevant field
Desirable:
Master's Degree in any one of
thesubject detailed under preitem1above from a recognized
University
Basic (HSC)-50
Degree-40
Desirable-experi-10
EE seniority-15
GEN-1
10
Speech Therapist/
Audiometry
Technician
PB-2-Rs.
930034800+
Grade Pay
4200
2
Not exceeding
35 years
6
07
Health Educator
PB-2-Rs.
930034800+
Grade Pay
4200
Essential:
Bachelor's Degree in Orthotics
and Prosthetics from a
recognizedinstitution
(or)
Diploma in Orthotics and
Prosthetics from a recognized
Institution or equivalent with two
years experience in an Orthotic
and Prosthetic workshop
Not exceeding
35 years
5
06
Orthotic and
Prosthetic
Technician
2
Not exceeding
32 years
4
05
Occupational
Therapist
Not exceeding
35 years
3
04
Not exceeding
35 years
2
PB-2-Rs.
930034800+
Grade Pay
4200
Essential:
Bachelor Degree in
Occupational
Therapy or its equivalent from
recognized institution
Desirable:
One year experience in the field
of rehabilitation
3 11
16
Dental Technician/
Hygienist
Photographer
PB-1Rs.520020200+
Grade Pay
2400
PB-1Rs.520020200+
Grade Pay
2400
4
(2+2)
Essential:
1. HSC or its equivalent
2. Diploma in Health Education
from a recognized University for
Health Inspector post
3. Diploma in Sanitation course
for Sanitary Inspector post
Basic (SSLC)-50
HSC & Diploma in
HE/SC-50
EE seniority-15
4
Essential:
1. HSC or equivalent
2. Diploma in Dental Mechanic
course from a recognized
institute
3. Diploma in Dental Hygienist
course from a recognized
institute
Basic (SSLC)-50
HSC & DiplomaDM/DH-50
EE seniority-15
Essential:
1. HSC or its equivalent
2. Diploma in Photography of a
recognized institute/University
or equivalent
3. Two years experience in
Medicalphotography in a
recognized Hospital
4. Computer knowledge.
Basic (SSLC)-50
HSC & Diploma with
experi.+ comp.know50
EE seniority-15
1
GEN-2
GEN-3
Not exceeding
32 years
Not exceeding
32 years
Basic (SSLC-50
ITI with experi-50
EE seniority-15
GEN-4
PB-1Rs.520020200+
Grade Pay
2400
3
GEN-4
15
Health Inspector/
Sanitary Inspector
PB-1Rs.520020200+
Grade Pay
2400
Essential:
1. SSLC or equivalent
2. Two years ITI Trade
certificate
in electronics from recognized
institution
3. Two years experience in
handling and maintenance of
audio visual equipments.
GEN-1
10
14
Audio Visual
Assistantcum-Storekeeper
2
Not exceeding
32 years
9
13
Health Visitor
Not exceeding
32 years
8
11
Basic (HSC)-50
Degree & Diploma
with experi-50
EE seniority-15
Not exceeding
32 years
7
PB-1Rs.520020200+
Grade Pay
2800
Essential:
1. Bachelor Degree in Botany /
Zoology/Home
Science/Nutrition/
Chemistry/Social Science/Social
Anthropology (10+2+3 system)
from a recognized University or
its equivalent
2. Diploma/Certificate in Public
relations/Health
education/Health Visitor course
or equivalent from
recognized institution
3. One year experience in the
relevant field
4 OR Assistant
40
Basic (SSLC)-50
Diploma with Boiler
Competency Certi-50
EE seniority-15
GEN-4
18
PB-1Rs.520020200+
Grade Pay
1900
Essential:
1. SSLC or equivalent
2. One year training as
Operating Room Assistant from
a recognized institute or
equivalent
Experience:
one year experience as an
operation theatre Assistant in a
major recognized hospital.
Not exceeding
32 years
13
17
4
Essential:
1. A pass in three years Diploma
in Mechanical Engineering (or)
equivalent in the relevant field.
2. Boiler Competency Certificate
from a recognized institute.
Not exceeding
32 years
12
Boiler Attendants/
Gas Plant Attendant
PB-1Rs.520020200+
Grade Pay
2400
SSLC with training50
Training &experi- -50
EE seniority-15
GEN23
MBC-7
SC-6
OBC-4
EXSM
-4
DAP-1
MSP-2
LAST DATE FOR RECEIPT OF APPLICATIONS BY POST OR IN PERSON UNDER (B) CATEGORY:
Filled in applications should be submitted along with the attested photo copies of the requisite testimonials by
“Registered Post with Acknowledgement Due” (or) “in person” dulysuperscribing on the cover as
“APPLICATION FOR RECRUITMENT TO THE POST OF …………………………” (specify the name of the post),
so as to reach “The Director, Indira Gandhi Medical College & Research Institute, Vazhudavur Road,
Kathirkamam, Puducherry-605 009” on or before 19/12/2014 at 5.00 P.M.
Note:
1.
The number of vacancies and reservations for various categories indicated above are only provisional and
subject to variation depending upon the requirementin IGMC&RI, Puducherry.
2.
50% of marks in basic educational qualification viz. SSLC/Matric/HSC/Diploma/Degree or equivalent and
50% of marks in the essential educational and technical qualifications including weightage for desirable
qualifications wherever applicable, as noted against each post.
3.
A deduction of 5% of marks will be made for every additional attempt either to pass the examination or to
improve the results, while computing the marks for educational and technical qualifications in respect of all
the above mentioned posts. Candidates who have passed the Degree/Diploma/SSLC/Matric or its
equivalent within the academic year but made additional attempt/supplementary examination will also be
counted as additional attempt while computing the marks.
4.
Apart from the above computation, 1.5 marks will be awarded for every completed year of seniority from
the date of registration of requisite educational or technical qualification, wherever applicable, in the
Employment Exchange till last date for receipt of duly filled in application on online and will be added
subject to a maximum of 15 marks in respect of each of the above mentioned posts.
5.
The qualifying marks will be calculated as above to the total of 115 (50+50+15) marks.
AGE LIMT:
Age as on 19/12/2014 which is the last date of receipt of applications will be reckoned as indicated above
against each post. Age limit is relaxable for OBC, MBC, BT, BCM, EBC, SC, ExSM,MSP, DPA (PH), Widows /
Divorced Women /Women judicially separated applicants and In-service officials as detailed below:
5 Category
OBC, MBC, BT, BCM, EBC
SC
Ex-Servicemen
Relaxation of Upper Age Limit
3 years
5 years
Length of service in Army, Navy and Air force of Indian Union
plus 3 years
Meritorious Sports Person
Upto 5 years (10 years for SC)
Differently Abled Person (DAP)/
10 years (in respect of reserved applicants, over and above the
Physically Handicapped (PH)
admissible relaxation of 5 years for SC and 3 years for
OBC/MBC/BT/BCM/EBC)
Widows/Divorced
Women/Women Upto the age of 32/35 years (upto 40 years for SC)
judicially separated from their husbands
and who are not re-married
Relaxable for Government servants upto 40 years of age (45
In-service Officials
(Departmental or other Government years for SC) in accordance with the instructions or orders issued
by Central Govt. provided such Government servants are working
Institutions)
for not less than 3 years in posts which are in the same line or
allied cadres and where a relationship can be established that the
services rendered by them in the Department will be useful for
efficient discharge of duties in the post for which selection is
made.
Note: Abbreviations:
Gen-General, OBC-Other Backward Class, MBC-Most Backward Class, BT-Backward Tribe, BCM-Backward
Class Muslims, EBC-Extreme Backward Classes (Meenavar Community), SC-Scheduled Caste, EXSM-ExServiceman, DAP-Differently Abled Person (PH-Physically Handicapped), MSP-Meritorious Sports Person.
GENERAL INFORMATION / INSTRUCTIONS TO THE CANDIDATES
1.
Applicants are instructed to read carefully the information and Instructions issued in this regard before
filling up of the application.
2.
Applicants should note the computer generated unique Application Numberfor their reference in the case
of Online applications
3.
Applicants are advised to have a copy of the Online generated application / the Directapplication for their
reference.
4.
Candidates from other States/Union Territories are not eligible to apply for all the posts.
5.
The applicant should necessarily submit the attested copies of the following testimonials along with the
Online generated application:(a)
Birth Certificate/Transfer Certificate or Board/University Certificate indicating Date of Birth for age
proof.
(b)
S.S.L.C./Matriculation or its equivalent and Higher Secondary or its equivalent Mark Sheets.
(c)
Necessary Degree / Diploma Certificate with all Marks Sheets (year-wise / semester-wise)
including attempts made, if any.
6 (d)
Registration as Pharmacist in Puducherry Pharmacy Council under Pharmacy Act alone will be
accepted, duly renewed as on date.
(e)
Prescribed number of years of Experience should be fulfilled and Certificate related to concerned
post should be submitted.
(f)
Resident /Nativity Certificate: Both Residents and Natives should have a continuous residence
in the Union Territory of Puducherry for the last 5 years immediately preceding the date of
notification and they are only eligible to apply for the posts. (Note: Certificate issued on or after
01/06/2014 and duly valid Permanent Integrated Certificate (PIC) and certificates already issued
by the Competent Authority will only be accepted).
(g)
Scheduled Caste / Scheduled Tribe / Other Backward Class for employment purpose obtained
from the Competent Authority of the Department of Revenue and Disaster Management,
Puducherry / Karaikal / Mahe/Yanam not below the rank of Executive Magistrate/Tahsildar/Deputy
Tahsildar as the case may be issued on or after 01/06/2014 and duly valid Permanent Integrated
Certificate (PIC) and certificates already issued by the Competent Authority will only be accepted.
(h)
Employment Exchange Identity Card duly renewed as on date, bearing NCO code Nos.for the
qualifications acquired by the candidate.
(i)
Candidates who have to apply against the horizontal reservation provided for Ex-Servicemen,
Meritorious Sports Person and Differently Abled Person (PH), should necessarily submit the
relevant certificates issued by Department of Sainik Welfare, Puducherry, Office of the Deputy
Director (Sports and Youth Services), Education Department, Puducherry and Department of
Social Welfare / Health & Family Welfare Services/Medical Authorities, Puducherry along with
related records in the prescribed format only. Certificates received from any other authority will not
be accepted.
Note:- Original Educational / Technical Qualification Mark Sheets/Certificates should not be
attached with the application
6.
(i)
Applicants who have acquired the Diploma/Degree under open University Stream are not eligible
for Direct Recruitment.
(ii)
The prescribed educational qualification and technical qualification acquired through regular
course should have been completed prior to the last date for receipt of dulyfilled in Online
generated application / By Direct application.
(iii)
If migrant certificates are submitted in respect SC/ST/OBC, their applications will be considered
against General/Un-reserved category.
(iv)
Certificate for employment purpose obtained from the Competent Authority of the Department of
Revenue and Management, Puducherry/Karaikal/Mahe/Yanam in the prescribed form alone will
be accepted.
7.
The applications which are not in complete shape, or without signatures both in application and checklist
and without enclosing the requisite certificates/mark sheets etc. as indicated above, will be summarily rejected and
further correspondence will not be entertained for any reasons therefor. The candidate shall ensure himself/herself
that all the requisite attested copies of certificates are attached along with his/her Online generated application / By
Post / In person application within the due date for submission and the Institution will not be responsible for any
7 lapse in this regard. Attested copies of certificates left out if any proposed to be enclosed after the due date of
submission of Online generated application by the candidate will not be accepted and the requisition in this regard
will not be entertained on any account. No intimation will be given for receipt of late/incorrect/ineligible applications
and also the result of recruitment would not be intimated on any account to the non-selected candidates. Only the
selected candidates will be issued offer of appointment. No correspondence or interim enquires from the
candidates will be entertained in this regard.
8.
The applications received after the prescribed date, time and applications, which are incomplete or wrongly
filled in shall not be considered and such applications, will not be returned to the candidates.
9.
Change of address, if any, after submission of the application should be intimated in time to the Institution
or otherwise the Institution will not be responsible for any postal delay/non-delivery of letters etc.
10.
Candidates should submit only one application for the post concerned. If the candidate desires to apply for
more than one post, they should apply separately for each post. COMMON APPLICATION FOR TWO OR MORE
POSTS WILL NOT BE ACCEPTED.
11.
Advance copy should not be sent and it will not be considered.
12.
The Director, Indira Gandhi Medical College & Research Institute, Kathirkamam, Puducherry reserves the
right to enhance/reduce the number of vacancies and also to cancel the recruitment process, if necessity arises.
The decision of the Institution shall be final regarding the eligibility of candidates or otherwise.
DIRECTOR
8 IND
DIRA GA
ANDHI MEDICAL COLLEG
GE & RES
SEARCH
H INSTITU
UTE
(Governmennt of Puducheerry Institution)
VazhudavurRoad,Kaathirkamam
m, Puducheerry-605 0099
APPLICA
ATION FOR DIRECT REC
CRUITMENT TTO THE POS
ST OF __________________________________
Name of
o the Post
Post Code Numbber
Affix recentt passport
size (3.5 cm
m x 4.5 cm)
photograph duly
d attested
by a Gazettted Officer
Applicant’s Speecimen Signaturre :
1.Name of thee Applicant (in BLOCK lettters):
H
Naame:
2. Father’s / Husband’s
3. Mother’s Name:
N
4. Date of Birth
:
5. Age as on 20/11/2014
:
D
Yeear
6. Gender
D
Month
M
M
Y
Y
Y
Y
Day
f female):
(write ‘M’ for Male / ’F’ for
7. Address:
A
Address
for communicatio
c
on:
ddress:
Peermanent Ad
PIIN
PIN
N
mber
8. Mobile Num
:
9. E-mail I.D.
:
9
10. Essential Educational Qualifications required for the post (Please enter from SSLC onwards):
Sl.
No.
Qualification
Name of the
Board/University/
Institution
Marks
Obtained
Max.
Marks
No. of
Attempts
Month &
year of
passing
Employment
Exchange
Registration
Date
No. of
Attempts
Month &
year of
passing
Employment
Exchange
Registration
Date
11. (a) Desirable Qualification required for the post:
Sl.
No.
Qualification
Name of the
Board/University/
Institution
Marks
Obtained
Max.
Marks
11. (b) Desirable Experience Certificate required for the post:
Sl.
No.
Office / Employer
Address
Post held
12. Nationality
From
Whether
Regular/
Temporary
:
Yes
13. Is Native / Resident of U.T. of Puducherry
with continuous residence for last 5 years?
:
14. Religion
:
15. Community / Caste
(Whether belongs to UR/MBC/SC/OBC/BCM/EBC/BT)
16. Special category
(Whether Ex-Serviceman /
Meritorious Sports Person /
Differently Abled Person (DAP / PH)/
Widowed/Divorced Woman)
No. of years
& months
(Experience)
To
Caste
:
No
Tick appropriate box
Origin
Migrant
:
10 17. Whether employed in Central / State Govt./
Public Sector Undertaking / Autonomous Body:
18. Details of Employment Exchange Registration :
(a)
(b)
(c)
Region
:
Registration Number
:
Validity Date / Next Renewal Date:
19. Identity Certificates:
Sl.No.
1
2
3
Name of I.D.
Ration Card
Voter ID Card
Adhar Card
Number of the I.D.
20. Caste/Nativity/Resident Certificates:
Sl.No.
1
2
3
Name of Certificate
Permanent Integrated
Certificate (PIC)
Nativity/Resident
Certificate
Certificate Number
Date of issue
Taluk Office/ Institution
Caste Certificate
DECLARATION
1.
I have thoroughly gone through the recruitment details/general instructions provided in the Recruitment
Details for inviting applications and clearly understood the contents of the same.
2.
I further declare that I fulfill all the conditions of eligibility regarding age limit, educational qualification etc.,
prescribed for this post.
3.
I also declare that I have never been convicted by any court of law. I also declare that no charge sheet is
pending against me in any court of law.
4.
I understand that in the event of any information/materials furnished in my application, if subsequently on
verification found to be false or incorrect or suppressed, my candidature at any stage is liable to be
cancelled.
5.
I further understand that, in case, I am appointed in service in the Institute based on the false and untrue
information furnished by me, my services are liable to be terminated forthwith without any notice.
6.
I further understand that if my application is found incomplete/defective, the same is liable to be rejected
summarily and no correspondence will be entertained in this regard.
7.
I also hereby declare that all statements made in this application are true, complete and correct to the best
of my knowledge and belief.
Place:
Date:
SIGNATURE OF THE APPLICANT
11 CHECK LIST FOR THE POST OF ______________________
Please enclose copy of the testimonials as per the order mentioned below and indicate the page
number invariably of all copies from 1 to the last copy of the testimonials
Sl.No.
1
2
3
4
5
6
7
8
9
10
11
Attested copies of the Certificates
Whether
Enclosed
(‘Yes’ or
‘No’)
If ‘Yes’ indicate
the Page No.
From
To
Attested copy of Birth Certificate/Transfer Certificate/Board or
University Certificate indicating date of birth
Attested copy of educationalqualification Certificates prescribed in
the ‘General Information/Instructions to Candidates’ (SSLC, HSC
etc.)
Attested copy of educational/technical qualification Certificates
prescribed in the ‘Information/Instructions to the Candidates’
(Essential, Desirable qualifications & others)
Attested copy of Diploma/Degree Mark Sheets (yearwise/semester wise)
Attested copy of Experience Certificate wherever it is necessary
Attested copy of Caste Certificate for MBC/SC/OBC/BCM/EBC/BT
issued on or after 01/06/2014
Attested copy of Nativity/Residence issued on or after 01/06/2014
Attested copy of Certificate for Ex-Serviceman wherever it is
necessary, with related records
Attested copy of Certificate issued for Meritorious Sports Person
Attested copy of Certificate for Differently Abled Person/Physically
Handicapped person wherever it is necessary with related records
Attested copy of Employment Exchange Registration Card
CHECK LIST DECLARATION
I have enclosed all the copies of testimonials as per the Check List order and numbered the copies of the
testimonials from page No.1 (first page of the copy of the testimonial) to _____ (last page No. of the copy of the
testimonial). I further declare that no copy of the testimonials is left out without numbering and the page nos.
mentioned in the check list are correct to the best of my knowledge and belief. I declare to ensure that all copies
have been enclosed and will not approach the Department in future to enclose/remove any certificates from the
application.
Place:
Date:
Signature of the applicant
- ---------------------------------------------------------------------------------------------------------------------------------------------------ACKNOWLEDGMENT
Application No._________
Received application from ________________________ for the post of ___________________________
Place:
Date:
Signature with Seal
12