JAWAHARLAL INSTITUTE OF POSTGRADUATE MEDICAL EDUCATION AND RESEARCH PUDUCHERRY - 605 006

(An Institution of National Importance under the Ministry of Health & FW, Govt. of India)

APPLICATION FORM - JIPMER RECRUITMENT 2013-14

Notification No & Date Application No. 01. 02. 03. 04. 05. 06. 07. 08. 09. 09a. 09b. 09c. 10. 10a. 11. 12. 12a. 12b. 12c. 12d. 13. 14. Basic Qualification (10th / 12th) Posts to which applicant wishes to apply Name Father's Name Mother's Name Gender Nationality Category Whether Ex-Serviceman Date of joining Date of Discharge Length of Service Is Person with Disability? ( PwD ) Code Is Meritorious Sports Person ? ( MSP ) Is Government Employee? Name of the Organisation Address of the Organisation Date of joining No of Years of service Date of Birth Age as on 19.01.2014 : Admn-I/Rect.C/2(10 )/2013 Dt. 21.07.2013 : 1035179 : 12th/Diploma : MULTI TASKING STAFF(MTS) : T. GANESH PRABHU : TAMIL SELVAN. B : GOVARTHANAMBIGAI. T : Male : Indian : OBC : No : N/A : N/A : N/A : No : N/A : No : No : N/A : N/A : N/A : N/A : 08 May 1988 : 25 -Year(s) ADDRESS FOR COMMUNICATION 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Address Line 1 Address Line 2 Address Line 3 City / Town District State / UT PIN Code Phone Mobile E-Mail ID Payment Mode : NO. 1B AHIMSHAPURAM 7th STREET : SELLUR : NILL : MADURAI : Madurai : Tamil Nadu : 625002 : NILL : 9994164739 : heyganesh88@gmail.com : Online Payment

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PAYMENT DETAILS 26. 28. Amount Payment Date : 300 : 18 Jan 2014 27. Transaction ID / DD No : DU03173332 29. Bank Name EDUCATIONAL QUALIFICATIONS S.No.
1 2 10th 12th/Diploma

: state bank of india

Educational Qualification

Percentage of Marks
84 76 Tamil Tamil

Medium

Board / Authority
State Board/SSLC State Board/SSLC

DECLARATION BY THE APPLICANT I hereby declare that I have read the advertisement, instructions and am conversant with the process of online submission of application. I hereby declare that I am an Indian National. I understand that the fees once paid will not be refunded under any circumstances. I hereby convey my willingness to produce all certificates/documents in original, whenever directed to me, that are relevant to my claims made in the application. 5) I also understand that my claim for admission will be cancelled forthwith in the event of my failure to produce the abovementioned original certificates/documents. 6) I hereby declare that I shall abide by the Rules and Regulations in force in this regard. 1) 2) 3) 4) I ALSO HEREBY DECLARE THAT I AM FULLY AWARE OF AND CONVERSENT WITH THE FOLLOWING AND THAT I WILL ABIDE BY THE RULES AND REGULATIONS OF THE INSTITUTE WITH REGARD TO THIS RECRUITMENT, FAILING WHICH MY CANDIDATURE MAY BE CANCELLED WITHOUT ANY FURTHER INTIMATION: 1. 2. 3. 4. 5. 6. My Registration ID may be valid till 6 p.m. of closing date 19.01.2014 only I have not submitted any other applications for this examination. I am aware that if I contravene this rule, my application will be rejected summarily by the Institute. I have read the provisions in the Notice of the examination carefully and I hereby undertake to abide by them. I further declare that I fulfill all the conditions of eligibility regarding age limits, educational qualifications etc., prescribed for admission to the examination. 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. Further declare that I have never been dismissed or removed from Govt. Service or my service been terminated during probation. For Central Govt. Civilian Employee seeking age relaxation : I declare that I am a Central Govt. Civilian Employee and completed 3 years regular service or regular length of service stipulated in the Notice of the examination on or before date of closing of submitting application form given in the Notice. 7. For Candidate belonging to OBC : I declare that I belong to the community which is recognized as a backward class by Govt. of India for the purpose of reservation in service as per orders contained in Deptt. of Personnel and Training office memorandum No. 36012/22/93- Estt. (SCT) dated 8.9.1993. I also declare that I do not belong to the person/sections (creamy layer) mentioned in column 3 of the schedule of the OM mentioned above and modified vide Govt. of India DOPT OMs mentioned in the notice. I further declare that I am in possession of OBC Certificate in the prescribed format given in the Notice of the examination 8. For Ex-Serviceman Candidates : I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of exam and I have not availed employment in civil side under Central Government as Ex-servicemen. I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found suppressed/false or incorrect or ineligibility being detected before or after the examination, may candidature/appointment is liable to be cancelled without further intimation.

Place : Madurai Date : 18-Jan-2014 01:52:26 PM

IP Address - 198.57.180.240

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Applicant Signature

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