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    BMC01072024 A3

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    kaushalzangidb

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    © All Rights Reserved
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    BMC01072024 A3

    Uploaded by

    kaushalzangidb
    2 views2 pages

    Original Title

    BMC01072024_A3

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    Copyright:

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    2 views2 pages

    BMC01072024 A3

    Uploaded by

    kaushalzangidb

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Annex – III

    APPLICATION FORM
    Affix Passport Size
    Application for Engagement of Bank’s Medical Photo
    Consultant on contract basis with fixed hourly
    remuneration at RBI, Kanpur

    1. Name in full:
    Shri/Kum. /Smt. ________________________________________________________________________
    (To be given in block letter, Surname to be stated first)
    2. Father/Husband’s
    Name: __________________________________________________________

    3. Addresses:
    (a) Local
    Residence
    Address
    (b) Permanent
    Residence
    Address
    (c) Dispensary /
    Hospital Address
    (where presently
    working)
    (d) Telephone No.
    (e) Mobile No.
    (f) Email ID.
    (g) Approximate distance of residence & Dispensary from the Bank’s Dispensary located at:
    Distance from Local Distance from
    Address
    Residence Dispensary/Hospital
    Reserve Bank of India Officers
    Quarters, 4 / 277, Tilak Nagar,
    Kanpur - 208002.

    4. Date of Birth:
    D D M M Y Y Y Y
    5. Place of Birth and Domicile:

    6. Nationality:
    7. Whether belongs to SC ST OBC GEN
    SC/ST/OBC/Unreserved
    Educational Qualifications:
    8. (Indicate degree/ diploma obtained in the order of highest to least)

    Degree/Diploma University/Board Year of Passing

    Particulars of any other


    9. courses completed in medical
    field:
    10. Details of experience – (Experience after graduation only should be stated):

    Experience at: From To Period (Year/s)

    In Hospital (as a Physician)

    As General Practitioner

    Any other factors which the


    applicant would like to bring
    11.
    into account for considering
    his/her application:

    I hereby declare that the information and particulars given by me in this form are true and
    correct. I also note that if any of the above statements are incorrect or false or if any material
    information or particulars has been suppressed or omitted there from, my engagement is liable
    to be terminated without notice or compensation in lieu thereof.

    Date:
    Place: (Signature of the applicant)

    INSTRUCTIONS:

    a) All the details in the Application Form are to be filled up completely by the applicant,
    as incomplete Forms are liable to be rejected.
    b) Attested copies of relevant certificates regarding age, educational qualifications,
    caste, experience etc. should be attached with the Form.
    c) In support of the experience gained by the applicant the Certificate submitted must
    contain the details of duty hours and the nature of duty.

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