APPLICATION FORM REGIONAL INSTITUTE OF MEDICAL SCIENCES, IMPHAL APPLICATION FOR THE POST OF NURSING OFFICER, 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 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 Details of Examination passed from Matriculation/School leaving certificate on wards: Sl.No. Name of School/College with Address Name of Board/Council/University Examination passed & year of passing Division/ Class obtained % of marks obtained 1 2 3 4 5 Experience: Sl.No. Name of Office/Institute/Org. Post (s) held Period of service Nature of job Reason of leaving 1 2 3 4 5 Affix recent passport size photograph Signature Whether No Objection certificate from the Employer is attached, if not, reason thereof: I hereby declare that the entries made in this form as above 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.
