JLZ GD"N Nl1F6 U]HZFT I]lGJl;"8L4

pWGF v DUN<,F ZM04 J[;]4 ;]ZT v #)5__*P

SM,[HMV[ VF5JFGL VG[ :YFlGS T5F; ;lDlTV[ RSF;JFGL DFlCTL DF8[G]\ lGIT 5+S

NZ[S 0LU|L 5|MU|FD DF8[ V,UYL VF OMD" EZJ]\

slOlhIMY[ZF5L VeIF;S|D DF8[f

(1) / SM,[HG]\ GFD VG[ ;ZGFD]\ / :
(2) / l0U|Lv5|MU|FDG]\ GFD / :
(3) / VF l0U|L 5|MU|FDDF\lJS<5M(Specialization )GF GFD / :
(4) / JU"NL9 ;\bIF
(< 60, > 100) / :
(5) / JUM"GL ;\bIF / : / F. Y. _____, S. Y. _____ , T. Y. _____,
(6) / S], lJnFYL"VMGL ;\bIF / : / F. Y. _____, S. Y. _____ , T. Y. _____, Total ____
(7) / X{1Fl6S :8FO ;\AlWT DFlCTL : (XFP lX1F6GF jIFbIFTF VG[ U|\Y5F, ;lCT f
(A) JUM"GL ;\bIF TYF lJQFIJFZ SFI"EFZ
S|D / lJQFI / F. Y. / S.Y. / T.Y. / Total
S],
JUM" / S],
TF; / S],
JUM" / S],
TF; / S],
JUM" / S],
TF; / S],
JUM" / S],
TF;
1.
2.
.
.
S],

-2-

(B) lJQFI slJEFUfJFZ VwIF5SMGL ;\bIF TYF SFI"EFZ (HM lJQFI V[S YL JW] l0U|L 5|MU|FDDF\ E6FJJFDF\
VFJTM CMI TM T[JF NZ[S l0U|L 5|MU|FDDF\ T[G[ ;DFJJMPf
S|DF\S / VwIF5SG]\ GFD TYF lGD6}\SGM 5|SFZ
sSFIDL q SZFZ VFWFlZTf / I]lGP GL DFgITFGF 5+GL TFZLB VG[ G\AZ
s V[SvV[S GS, AL0JLf / JQF"q ;[D[:8Z NL9 SFI"EFZ
sS], TF;f / S], TF;
sTF;GF S,FSMf
(5|[Sl8S,GF 2 S,FSM = V[S S,FSGM 1 TF; )
5|YD / lålTI / T'TLI
(I) lJQFI o
s!f
sZf
.
.
(II) lJQFI o
s!f
sZf
.
.
(III) lJQFI o
s!f
sZf
.
.
s GM\W o H~lZIFT VG];FZ SMQ8S ,\AFJJ]\f

-3-

(C) VF l0U|L 5|MU|FDGM S], SFI"EFZ sTDFD lJQFIM ;FY[f VG[ VwIF5SMGL lGD6}\SGL DFlCTL sXFPlX1F6GF jIFbIFTF
TYF U|\YF,I ;lCTf o
S|D / lJQFIG]\ GFD / H~ZL VwIF5SMGL ;\bIF / I]lGJl;"8L V[5|]j0 lX1FSMGL ;\bIF / B}8TF lX1FSM
1 / XFZZLS lX1F6 / 1
2 / U|\YF,I / 1
3
4
.
.
.
VF l0U|L 5|MU|FD DF8[
(i) SFIDL H~ZL VwIF5SMGL S], ;\bIF sTDFD lJQFIM D/LG[ f : ______
(ii) I]lGJl;"8L DFgI ;\5}6" ,FISFT WZFJTF s Ph.D. / NET / SLET GL XZT 5}6" YTL CMI T[JF f S], SFIDL
VwIF5SMGL ;\bIF : ______
(iii) SFIDL lGD6}SGL 8SFJFZL _____% (iv) 38TF SFIDL VwIF5SMGL 8SFJFZL : ______%
(DFlCTL V,U ;L8DF\ VF5JLf
(8) / VFRFI"G]\ GFD
(I]lGJl;"8L DFgITFGF 5+GL GS, lA0JL) / : / ______
(9) / X{1Fl6S TYF JCLJ8L :8FOG[ R}SJFTF 5UFZ ;\A\lWT DFlCTL o
(i) 5UFZ WMZ6 / : / 5F\RD] / K9]\ 5UFZ 5\R o
(ii) DM\WJFZL EyY]\ % : ____ / (iii) 3ZEF0F EyY]\ o % :___ / (iv) (DM\PE +3Z EF0F EyY]\ ) % :____
(v) U|Fg8 .G V[.0Ÿ SM,[HDF\ R}SJFTF\(DA + HRA)GL 8SFJFZL s %) ______
(vi) Z[lXIM o (DA +HRA) : i.e.((iv) ÷(v)) : ______
(10) / Z5 S[ T[YL JW] SM,[HMV[ EFU ,LWM CMI T[JL I]lGJl;"8L £FZF VFIMlHT ZDTUDTGL ClZOF.VMDF\ EFU ,[JFGL DFlCTL
(i) SM,[HMV[ EFU ,LW[, CM. T[JL I]lGJl;"8L VFIMlHT ZDTUDTGL ClZOF.VMGL ;\bIF : _____
(ii) VF SM,[HMGF\ lJnFYL"VMV[ EFU ,LWM CMI T[JL ClZOF.VMGL ;\bIF : ______
(Please Provide on a Separate Sheet the list of events in which the college took Part)
(11) / Z5 S[ T[YL JW] SM,[HMV[ EFU ,LWM CMI T[JL I]JS DCMt;JGL CZLOF.DF\ EFU ,LWM CMI T[GL DFlCTL
(i) I]lGJl;"8L £FZF VFIMlHT ClZOF.VMGL ;\bIF : ______
(ii) VF SM,[H[ EFU ,LWM CMI T[JL ClZOF.GL ;\bIF : ______
(VF SM,[H[ EFU ,LW[, CMI T[JL ClZOF.GL IFNL V,UYL lA0JL)

-4-

(12) / JCLJ8L :8FO ;\A\lWT DFlCTL s5|IMUXF/FGF :8FO ;lCTf
lGDFI[, / H~ZL
(i) C[0 S,FS"GL ;\bIF : ______/______
(ii) l;lGIZ S,FS"GL ;\bIF : ______/______
(iii) H]lGIZ S,FS"GL ;\bIF : ______/______
(iv) ;[JSMGL ;\bIF : ______/______
(v) VgI (:5Q8TF SZJL) : ______/______
S], : ______/
8SFJFZL : ______/ ______
(13) / I]lGJl;"8LG[ HM0F6GL OL TYF VgI OL R}SjIF V\U[GL DFlCTL
(i) VF l0U|L 5|MU|FDGL S], HM0F6VZHL OL
(i) ZL;L%8 G\AZ. ______TYF TFZLB : ______
(TDFD ZL;L%8GL V[S V[S GS, lA0JL)
(ii) lJnFYL"NL9 HM0F6 OL :
(a) lJnFYL"VMGL ;\bIF : ______(b) lJnFYL"NL9 ZSD : ______
(c) S], ZSD : ______
(TDFD ZL;L%8GL V[S V[S GS, lA0JL)
(iii) I]lGJl;"8L S[d5; 0[J[,M5D[g8 OL :
(a) lJnFYL"VMGL ;\bIF : ______(b) lJnFYL"NL9 ZSD : ______
(c) S], ZSD : ______
(TDFD ZL;L%8GL V[S V[S GS, lA0JL)
(iv) :5M8"; 0[J[,M5D[g8 OL:
(a) lJnFYL"VMGL ;\bIF : ______(b) lJnFYL"NL9 ZSD : ______
(c) S], ZSD : ______
(TDFD ZL;L%8GL V[S V[S GS, lA0JL)
(v) I]lGJl;"8L :5M8;"V[g0 S<RZ, V[S8LJL8L OL :
(a) lJnFYL"VMGL ;\bIF : ______(b) lJnFYL"NL9 ZSD : ______
(c) S], ZSD : ______
(TDFD ZL;L%8GL V[S V[S GS, lA0JL)

-5-

(14) / AMG;q5[G<8L 5M.g8 ;\AlWT DFlCTL o
(i) :8FO~DGL ;FY[ JMX~D GL jIJ:YF : / K[ / GYL ______
(ii) :8FO~D q S[d5;DF\ JF.OF.GL jIJ:YF : / K[ / GYL ______
(iii) lJnFYL"GLVM DF8[ SMDG~DGL jIJ:YF : / K[ / GYL ______
(iv) U|\YF,IDF\ V,U JF\RG DF8[GM ~D :
U|\YF,IDF\ p5,aW 5]:TSMGL ;\bIF o / K[ / GYL ______
______
(v) ZDT UDTG]\ D[NFG / : / K[ / GYL ______
(vi) 5|IMUXF/FDF\ H~Z D]HAGF ;FWGMGL p5,aWL o
sp5,aW ;FWGMGL IFNL 5|IMUXF/F DF8[ lA0JLf / K[ / GYL ______
(vii) SM,[H H[ DSFGq S[d5;DF\ RF,[ K[ T[DF XF/F S[ VF I]lGP
;FY[ ;\,uG GCL\ CMI T[JL ;\:YF RF,[ K[ S[ S[D m
sHM HJFA ' CF ' CMI TM 5[ZFv !5 DF\ VgI
VJ,MSGMDF\ lJUTM VF5JLPf / CF / GF ______
(viii) ;[JF5MYLDF\ lGIlDT GM\W SZJFDF\ VFJ[ K[P VG[ O.69
(A & B) GL HMUJF.VMG]\ 5F,G YFI K[P / CF / GF ______
(ix) ;[lDGFZq SMgOZg; DF8[ 0I]8L ,LJ VF5JFDF\ VFJ[ K[Pm / CF / GF ______
(x) I]lGJl;"8LGF SFD VY[" 0I]8L ,LJ VF5JFDF\ VFJ[ K[P m / CF / GF ______
(xi) D[GZ8LGL8L q 5[8ZGL8L ,LJ VF5JFDF\ VFJ[ K[ m / CF / GF ______
(xii) V[gZM,D[g8GL SFI"JFCL 5}6" YI[YL lJnFYL"VMGL
VMZLHLG, DFS"XL8 TYF ;8L"OLS[8 5ZT VF5JFDF\ VFJ[ K[P / CF / GF ______
(xiii) V[g8L Z[UL\U ;lDlT ZRFI[, K[ m / CF / GF ______
(xiv) HFTLI ;TFD6L ZMSJF DF8[ ;[,GL ZRGF SZJFDF\
VFJL K[P / CF / GF ______
(xv) I]lGJl;"8LV[ lGIT SIF" l;JFIGL VgI OL ,[JFDF\ VFJ[
K[ m / CF / GF ______
(xvi) lJnFYL"VMG[ 5|M:5[S8;" VF5JFDF\ VFJ[ K[ m / CF / GF ______
(xvii) 5|M;5[S8;"GL lS\DT H6FJMP / ~FP ______
(xviii) lJnFYL" ;\3 5|lTlGlW sSRC) GF lC;FAM VMl08
YI[, K[ S[ GCL m / CF / GF ______
(xix) UT JQF[" HM0F6 DF8[ I]lGJl;"8L £FZF H6FJ[, XZTMGL
;\bIF VG[ VF XZTM 5{SL 5lZ5F,G YI[, XZTMGL
;\bIF s5]ZFJFG]\ lA0F6 HM0J]\f / ______
______
(xx) AAA G]\ VMl08 YI[, K[ m / CF / GF ______
(xxi) SgIF KF+F,I K[ S[ GCL\ m / CF / GF ______
(xxii) S]DFZ KF+F,I K[ S[ GCL\ m / CF / GF ______

-6-

(15) / AMG; q 5[G<8L 5M.g8 D/L XS[ T[GF VgI D]NŸFVM q VJ,MSGM o
spPNFP TZLS[ s!f SM,[H H[ DSFGq S[d5;DF\ RF,[ K[ T[DF XF/F S[ VF I]lGP ;FY[ ;\,uG GCL\ CMI T[JL ;\:YF RF,[ K[ S[ S[D T[GL DFlCTL sZf lJnFYL" q :8FO DF8[ U|\YF,I q 5|IMUXF/Fq S[d5;q5LPV[OP JU[Z[DF\ lJnFYL"VMG[ D/JL HM.TL ;]lJWFGM VEFJ VYJF JWFZFGL ;]lJWF JU[Z[f
1.
2.
3.
.
.
.
(16) / ;NZ VeIF;S|DG]\ ZFHI ;ZSFZGF lX1F6 lJEFU4 UF\WLGUZ TZOYL 5|l;wW YI[, K[<,F\DF\ K[<,F HFC[ZGFDFGL GS, VF5JLP

VFYL VDM 5|DFl6T SZLV[ KLV[ S[ p5Z H6FJ[, DFlCTL VDFZL HF6 D]HA VG[ p5,aW VFWFZM D]HA ;FRL VG[ BZL K[P

VFRFI"GL ;CL ;\RF,S D\0/GF 5|lTlGlWGL ;CL

(GFD TYF l;SSM) ( GFD VG[ l;SSMf

VDM4 GLR[ D]HAGF ;lDlTGF ;eIMV[ p5ZMST DFlCTLGL RSF;6L SZL K[ VG[ p5,aW VFWFZM D]HA T[ ;FRL VG[ BZL K[P p5ZMST DFlCTL VG[ VJ,MSGMGF VFWFZ[ VDM ;NZ l0U|L 5|MU|FD DF8[ ;\:YFGL HM0F6GL VZHL U|FCI ZFBL GLR[GF ;DIUF/F DF8[ GJ]\q RF,] q SFIDL HM0F6 VF5JF E,FD6 SZLV[ KLV[ q SZTF\ GYLP

;DI UF/M o ______

XZTM :

(1)

(2)

(3)

.

.

GFD : ;CL :

(1) ______

(2) ______

(3) ______

sSM. 56 BFG]\ BF,L ZFBJ]\ GCL\f

sVF56L I]lGJl;"8L VF56]\ UF{ZJf

E:\SYN-AFFILIATION\LETTER\2016\FACULTYWISE LIC FORMATE\Physiotherapy Faculty.doc