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SHYAM SHAH MEDICAL COLLEGE, REWA(M.P.)
Fields marked with * are mandatory
Instructions
Documents to be furnished in original at the time of verification of documents along with one set of photocopies should be self attested and a copy of online submitted application form / Receipt
Personal Details
Applying for Post *
Examination City Center Name 1 * Examination City Center Name 2* Examination City Center Name 3*
Applicant's Name*
Father's/Husband's Name*
Mother's Name*
Domicile of MP:*
Category:*
Nationality:*
Whether the category of the applicant is under Saharia / Sahariya, Baiga or Bharia primitive tribes as per rule g of rule no.2?* District*
Gender*

Date of Birth(DD/MM/YYYY)* (In DD/MM/YYYY) Age as on 01/07/2019    - -(yy-mm-dd)
Marital Status* Marriage Date* (In DD/MM/YYYY)
No. of Children Last child birth date (In DD/MM/YYYY) Is Your Last Child Born Twins
Are You an employee of Goverment/Corporation/Group/ Autonomous organization?*
Are You Physically Handicapped?*
Type Of Physically Handicapped
Educational Qualification
Qualification Specialization Passing Year (In YYYY) University/Board Institute/College Name Obtained Percent (In 00.00 Format)
10th* 10th
12th*
Qualification obtained*
Master Degree
*
If yes,Registration No.
Experience In 300 Bed Hospital?
Experience Details
Do you have experience in Govt sector/ Semi Govt/ PSU/organization registered under Company /Firms & Society Act/ Registered NGO?*
SnoCompany NameFrom Date (In DD/MM/YYYY)To Date (In DD/MM/YYYY)Year (yy/mm/dd) 
1
    
Total Experience(yy/mm/dd)
Communication Address
Address*
State* City/Town* Pin No.*
Email id* Mobile No.*   Phone No.  
Permanent Address(Same as Communication Address)
Address*
State* City/Town* Pin No.*
Mobile No.* Phone No.
Bank Details
Account Number * Bank Name *
Account Holder Name * IFSC Code *
Attachment*
Attach Photo with Signature*
Click here for photo sign format
Declaration *
I HEREBY DECLARE THAT ALL THE INFORMATION GIVEN IN THE AFOREMENTIONED APPLICATION FORMAT IS TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERTAKE AND ACCEPT THAT IF ANY OF THE INFORMATION GIVEN BY ME IS FOUND TO BE INCORRECT, THEN MY APPLICATION WILL BE REJECTED AND IF APPOINTED, THEN MY APPOINTMENT WILL BE TERMINATED & ACTION MAY BE TAKEN ACCORDINGLY.