PRESCRIBED APPLICATION FORMAT FOR THE POST OF TUTOR, DENTAL COLLEGE, RIMS, IMPHAL Full Name in Block Letters Father’s/Husband’s Name Date of Birth Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year: 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 Age(as on the last date of Submission of application.) Category SC ST OBC GEN Gender Male Female E-mail ID Telephone/Mobile No. (10 digit number) Nationality (State whether by birth or by domicile): Permanent Address in full Present Address in full Do you belong to Schedule Caste/Schedule Tribe/OBC category?: (if yes please indicate and enclose a copy of the certificate) Yes No Details of Examination passed: Examination Name of School/College with Address Name of Board/Council/University Month & Year of passing Division/ Class obtained % of marks obtained 10+2/P.U.C. MBBS/BDS M.D./M.S./ M.Ch./D.M. / MDS with speciality DNB Teaching experience:(a) Before Post Graduation: Sl.No. Name of College/Institute/Org. Post (s) held Period of service Nature of Appointment (Regular/ Contract) Reason of leaving From To 1 2 3 4 5 Teaching experience:(a) After Post Graduation: Sl.No. Name of College/Institute/Org. Post (s) held Period of service Nature of Appointment (Regular/ Contract) Reason of leaving From To 1 2 3 4 5 Research works & Publications: Sl.No. Year of publication Name of Journal indicating Vol. no., Page no. etc. Title Indicate whether 1st Author or Co-author 1 2 3 4 Seminar/Workshop/ Conference attended: Sl.No. Year Name of event indicating participation Details of presentation 1 2 3 4 Whether you have published any book or contributed a chapter in a book? If so mention the name of the book, year of publication etc. Name of the book published Chapter contributed Year of publication Prizes and Awards received: Extra Curricular activities: Affix recent passport size photograph Signature I,Shri/Shrimati/Kumari declare as under: That I am unmarried/a widower/a widow. That I am married and have only one spouse living. That I have entered into or contracted a marriage with a person having a spouse living. Application for grant of exemption is enclosed. That I have entered into and contracted a marriage with another person during the lifetime of my spouse. Application for grant of exemption is enclosed. That I hereby declare that the entries made in format are true and correct to the best of my knowledge and belief. In the event of any information being found false/incorrect my candidature/services are liable to be terminated without any notice.
