APPLICATION Form for PMMSSY new AIIMS Faculty Positions

(Last date for receipt of application 31st Jan 2012)

Position & Institute

1. Advertisement Number / Faculty new AIIMS No. 1/2011
Dated / 28th Dec 2011
2. Applying For
(Please check One) / Professor Additional Professor
Associate Professor Assistant Professor
3. Subjects
(Please refer the advertisement for subjects.) / 1.
2.
3.
4. Want to be considered for
(Please check One) / Permanent Faculty
Deputation
Contractual
5. Institute Preference:
(Please check one box for each institute)
AIIMS Bhopal /  1 2 3 4 5 6 Do not consider
AIIMS Bhuvneshwar /  1 2 3 4 5 6 Do not consider
AIIMS Jodhpur /  1 2 3 4 5 6 Do not consider
AIIMS Patna /  1 2 3 4 5 6 Do not consider
AIIMS Raipur /  1 2 3 4 5 6 Do not consider
AIIMS Rishikesh /  1 2 3 4 5 6 Do not consider

Name & Address

6. Applicant Name:
(Title, First Name,
Middle Name,
Last Name)
7. Upload Photograph
(Color passport size): /
8. Birth Date:
(YYYY-MM-DD example 1962-11-19)
9. Sex: /  Female  Male  Do not want to Disclose
10. Indian Citizen: /  By Birth By Domicile  OCI Card Holder
11. Permanent Address Details :
a. Address:
b. City:
c. State
d. Pin:
e. Police Station:
f. Phone: / STD Code Phone1 Phone2
11. Correspondance Address Details :
a. Address:
b. City:
c. State
d. Pin:
e. Police Station:
f. Phone: / STD Code Phone1 Phone2
13. Mobile No. / Mob 1 Mob 2
14. Email:
15. Present Designation:
16. Institute Serving At:
17. No Objection Certificate:
18a.Registration:
18b.Registration Number:
19. Reserved Desired:

21. Educational Details

(If you have more than one professional diploma or additional qualifications, please add new rows.
* Extra Attempts- Number of extra attempts you took to get the undergraduate and postgraduate degree.)
Level / Degree / Institute / Award Year / Percent Marks / Extra Attempts
10th
12th
Undergraduate
Postgraduate
Doctorate/PHD
Additional Qualification
Professional Diploma

21. Professional Experience:

(Experience From 1st teaching post to current post. Please feel free to add additional sheets.)
1. Post / Institution / From / To / Salary
Nature Of Work :
Remarks :
2. Post / Institution / From / To / Salary
Nature Of Work :
Remarks :
3. Post / Institution / From / To / Salary
Nature Of Work :
Remarks :
4. Post / Institution / From / To / Salary
Nature Of Work :
Remarks :
5. Post / Institution / From / To / Salary
Nature Of Work :
Remarks :
6. Post / Institution / From / To / Salary
Nature Of Work :
Remarks :
7. Post / Institution / From / To / Salary
Nature Of Work :
Remarks :

22. Paper Published, If any

22(i).
Total number of papers published in indexed peer reviewed journals:
a). Number of case reports:
b). Number of case series:
c). Number of Cohort studies:
d). Number of Case Control studies:
e). Number of Randomized Control Trials:
f). Number of Meta Analysis:
g). Number of Validation of Diagnostics Tests:
22(ii). List your publications in Vancouver Style from latest to the oldest
1.
2.
3.
4.
5.
22(iii). Attach two best papers

Awards, Distinctions and Prizes, If any

(Awards, distinctions, prizes, fellowships, special trainings.
List the Citation of five best awards as 1, 2, 3, 4, 5. *)
23. Number of awards received:
Type / Description/Citiation / Awarding Institution or Body / Award Date
(YYYY-MM-DD)
Comments
Type / Description/Citiation / Awarding Institution or Body / Award Date
(YYYY-MM-DD)
Comments
Type / Description/Citiation / Awarding Institution or Body / Award Date
(YYYY-MM-DD)
Comments
Type / Description/Citiation / Awarding Institution or Body / Award Date
(YYYY-MM-DD)
Comments
Type / Description/Citiation / Awarding Institution or Body / Award Date
(YYYY-MM-DD)
Comments
Type / Description/Citiation / Awarding Institution or Body / Award Date
(YYYY-MM-DD)
Comments

24. Research Project, If any

Number of research projects in which you were principal Investigator: List with Title, name of funding body, year form to, amount of funding, status of the project (Complete, incomplete, List of publications from the project). Mention Total amount of Research Grants awarded to you as PI. Also mention in how much period of service. *
Project / Start Date
(YYYY-MM-DD) / End Date
(YYYY-MM-DD) / Funding / Project Status
Comments
Project / Start Date
(YYYY-MM-DD) / End Date
(YYYY-MM-DD) / Funding / Project Status
Comments
Project / Start Date
(YYYY-MM-DD) / End Date
(YYYY-MM-DD) / Funding / Project Status
Comments
Project / Start Date
(YYYY-MM-DD) / End Date
(YYYY-MM-DD) / Funding / Project Status
Comments
Project / Start Date
(YYYY-MM-DD) / End Date
(YYYY-MM-DD) / Funding / Project Status
Comments
Project / Start Date
(YYYY-MM-DD) / End Date
(YYYY-MM-DD) / Funding / Project Status
Comments
Total funding:

25. Technology Transfer and Patents, If any

Mention Technology Transfer and Patents if any contributed by you. *
Title / Year

26. Essay

Unique Selling Points: Write in not more than 250 words unique/special reasons why you are specially uniquely competent/motivated to help achieve the mandate of these Institute of National Importance “Creating a compassionate, competent, caring and motivate health work force with the logistics to reach out to the last man in the queue with the needed, most sophisticated but affordable health care technology.”

Everything else

27. Any extra curricular activity you can contribute to?  Yes No
(if Yes, Please Describe)
28. Enlist major scientific contributions Clinical / Teaching / Research/ administration -citing relevant references / strengths / innovative work / leadership role to prove your worth in medical education nationally and internationally.
29. Teaching experience in years:
Junior Resident 1
Junior Resident 2
Junior Resident 3
Senior Resident
Lecturer
Assistant Professor
Associate Professor
Additional Professor
Professor
Director
Any other Experience, Please specify
30. Detail the proof of payment of processing fee for this application.
31. Mention details if you are suffering from any Disease, Disability, Disorder.
32. Mention details, if you have ever been convicted by any court or administrative body in India or Abroad.
33. Kindly tell us the number of people who will live with you in the Institute in case you are selected to allow us to arrange a suitable accommodation.
34. If your spouse is also applying add his/her name and subject he/she is applying for.
Spouse Name:
Subject applied for.
35. Please specify the earliest date you can join
Earliest Joining date (YYYY-MM-DD)
For preclinical subjects candidate joining before 31st March 2012 will get weightage.

36. Documents

Please Review and check the Documents you may be bringing for the Interview
Age Proof
Residence Proof
Qualification Proof (MBBS, MS degree and marksheet)
NOC Documents (If applicable)
Reserve Category Documents
Experience Letter
Medical Registration Document
List any other Documents you may be bringing.
37. I agree that, information I am submitting in this application is true to the best of my knowledge and belief and I agree that if any discrepancy is found at any stage the application, all subsequent actions on this application will be taken to be legally void. Also, in such a case you may be submitted to such legal, financial or administrative action as the competent authority of the Institute, Government may deem fit at the time of the detection of such discrepancy. Incase of duplicate submission the later application will be taken to be authentic.

Signature Date

Name

(Faculty newAIIMS No. 1/2011/dated 28th-Dec-2011 Form ver 1.0)Page 1 of 12