SANJAY GANDHI POSTGRADUATE INSTITUTE OF MEDICAL SCIENCES, LUCKNOW.
Raebareli Road, Lucknow 226 014 (UP) India
APPLICATION FOR FACULTY POSITION
ADVT. NO ……………………
POST APPLIED FOR …………………………………………………………………………………
PLEASE
ATTACH
A RECENT
PHOTOGRAPH
HERE
IN THE SPECIALITY OF ……………………………………………………………………………..
…...……………………………………………………………………………………………………….
1.NAME IN FULL …………………………………………………………………………………………………………………………………….
(CAPITAL LETTERS)
FAMILY NAME
FIRST NAME
MIDDLE NAME
2. NAME OF FATHER ………………………………………………………………………………………………………………………………..
3. NAME OF MOTHER ……………………………………………………………………………………………………………………………….
4. MAILING ADDRESS ………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………….
STREET
CITY
PINCODE
……..…………………………………………………………………………………………………………………………………………………...
PROVINCE/STATE
COUNTRY
PHONE NO. (with STD code)……………………………………EMAIL ADDRESS (if any)………………………………………………………...
5. PERMANENT ADDRESS ………………………………………………………………………………….………………………………………
(PRINT ONLY IF DIFFERENT FROM ABOVE) STREET
CITY
PINCODE
……………………………………………………………………………………………………………………………………………………………
PROVINCE/STATE
COUNTRY
6. COUNTRY OF BIRTH ……………………………………… COUNTRY OF CITIZENSHIP………………………………………………...
7. DATE OF BIRTH ……………………………………… ……AGE IN YEARS …………………………………………………………………
DAY
MONTH
YEAR
IN WHOLE NUMBERS COMPLETED
8. SEX …………………………………
9.
MARITAL STATUS: SINGLE / MARRIED / SEPARATED / DIVORCED / WIDOWED
Scheduled caste
Yes
No
Scheduled tribe
Yes
No
Other backward cast
Yes
No
Ex-servicemen
Yes
No
Signature of applicant with date
Page 1 of 7
10. EXAMINATION PASSED (most recent first) date of appearing or passing; number of times attempted; grade/ class/division obtained
and institution/university from which passed may be mentioned. Where more than one professional examinations are required to
obtain a degree, information regarding each professional examination may be given Matriculation – Xth grade onwards).
No.
EXAMINATION
DATE
ATTEMPTS
GRADE / %
INSTITUTION
11. PRIZES, MEDALS, SCHOLARSHIPS ETC. AWARDED (mention only those related to the profession) giving brief description of the award.
NO.
Signature of applicant with date
DESCRIPTION
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SUMMARY OF QUALIFICATIONS
(Please submit 10 copies)
Advt. No. ………………………………… Item No. …………
Name of the Post ………………………………………….………
A. Name ……………………………………………………………..
B. Present Employment with present basic Salary & grade
Age………………………………………………………………..
…………………..………………………………………………
Qualifications ………………………………………………….
Minimum pay acceptable, if selected…………………….
Member of Scheduled Caste/Tribe/Backward class…….
Notice required for joining…………………………………
Whether applied through proper channel……………….
C
Academic Vitae (from Matriculation, Grade X on wards)
Examination
College/ Institution
University/
Board
Signature of applicant with date
Year
Subjects
% of Marks
obtained
Class
/Division/
Grade
Merit/Prizes
Medals won, If Any
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D.
Languages Known
Read
Write
Speak
E. Teaching Experience
Under-graduate classes………………………
F.
Research Experience.
Subject(s) taught………………………………….
…………………………………………………….
Post-graduate Classes………………………..
Subject taught………………………………….
Total in (years)………………………………….
G. No. of research papers
published
H. Books Published
I. No. Research Projects
J. No. of dissertations
supervised
National……………………………………
MD/MS
International………………………………
DM/MCh ………………
Ph. D.
………………
……………….
K. Reference & Testimonials
L. Additional Information.
Signature of the applicant____________________________
Date______________________________________________
Designation_______________________________________
Place of work______________________________________
Signature of applicant with date
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12. PROFESSIONAL EXPERIENCE (before obtaining prescribed qualification which makes you eligible for the post ) title of the post held,
data of joining, date of leaving, complete number of years spent (give in whole numbers ), nature of post (involving practice, teaching and
/ or research) and emoluments per annum, for each post.
No.
POST
INSTITUTION
DATE OF
JOINING
DATE OF
LEAVING
EXPERIENCE
MONTHS/DAYS
NATURE
OF JOB
REASONS FOR
LEAVING
EMOLUMENTS
13. PROFESSIONAL EXPERIENCE (after obtaining prescribed qualification which makes you eligible for the post).
No.
NAME OF THE
POST
INSTITUTION
Signature of applicant with date
DATE OF
JOINING
DATE OF
LEAVING
EXPERIENCE
IN YEAR/S
MONTHS/
DAYS
NATURE
OF JOB
REASONS FOR
LEAVING
EMOLUMENTS
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14. MEMBERSHIP OF PROFESSIONAL SOCIETIES/BODIES/ASSOCIATIONS ETC. Status whether fellow, member or associate
member etc. name of the society, body or association etc. and date of enrolment.
NO.
STATUS
NAME
DATE OF MEMBERSHIP
15. MAJOR INTERESTS/HOBBIE/EXTRA-CURRICULAR ACTIVITIES.
16.
RESEARCH EXPERIENCE together with details of published works (attach separate sheets of the size of each of the following) :
(a)
(b)
(c)
(d)
(e)
(f)
16.
PAPERS PUBLISHED.
PAPERS UNDER PUBLICATION.
PROFESSIONAL COURSES, SEMINARS/WORKSHOPS/CONFERENCES ATTENDED.
PAPER PRESENTED AT CONFERENCES.
VISITING PROFESSORSHIPS TO ACADEMIC INSTITUTIONS.
ANY OTHER.
PROFESSIONAL ACHIEVEMENTS. Print in up to 100 words your professional achievements in the specialty for which applied.
Signature of applicant with date
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18.
Name of three referees who can testify you suitability for the post applied.
a)
Name of Referee ………………………………………………………………………………………………..…………………………………..
………………………………………………………………………………………………………………………………………………………...
DESIGNATION
ORGANISATION
………………………………………………………………………………………………………………………………………………………...
STREET
CITY
PIN CODE
………………………………………………………………………………………………………………………………………………………...
PROVINCE/STATE
b)
COUNTRY
Name of Referee ……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………….
DESIGNATION
ORGANISATION
………………………………………………………………………………………………………………………………………………………..
STREET
CITY
PIN CODE
…………………………………………………………………………………………………………………..…………………………………….
PROVINCE/STATE
c)
COUNTRY
Name of Referee …………………………………………………………..…………………………………………………………………………
…………………………………………………………………………………………………………..…………………………………………….
DESIGNATION
ORGANISATION
……………………………………………….……………………………………………………………………………………………………….
STREET
CITY
PIN CODE
……………………………..………………………………………………………………………………………………………………………….
PROVINCE/STATE
19.
COUNTRY
Present Employment……………………………………………………………………………………………………………………………….
……………………………………………………………………………………..………………………………………………………………….
DESIGNATION
ORGANISATION
20.
Annual Pay Rs …………………………………………………………………………………………………………………………………….
21.
What salary would you accept ?……………………………………………...…………………………………………………………………
Please consult, job specification of the post applied for
(mention only basic salary within the scale)
22.
What notice would you require before joining (in months)? ………………………………………………………………………………
I certify the above particulars submitted are correct and in case they are inaccurate, the Institute would be free to take action against me.
Place
Date
Signature of applicant with date
Signature…………………………………...
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