INDIAN COUNCIL OF MEDICAL RESEARCH

ANSARI NAGAR NEW DELHI-110029

1. Name of the Project : Database of Potential Chemical Leads Photo

2. Applying for the Post of :

3. Name of the Candidate :

(In Block Letters)

4. Fathers Name :

5. Date of birth / : _____________ / _______________Yrs.

Age in completed years

6. Sex : Male / Female

7. Address : --------------------------------------------

-----------------------------------------

8. Mobile Number :
9. E-mail ID :

10. Educational Qualification

a) Essential Qualification
Sl. Exam passed Year of Board /University % of Marks
No passing
 b) Desirable Qualification as per advertisement

11. Work Experience (Total Number of Years)

Sl Period
Post held and
No Name of the Employer (Date/month/year) responsibilities
(Name of the
office/Institution) From To
 12. Any other Research Experience / Information

13. Check List

S. (Please tick)
No.
1 Documentary proof of date of birth (PDF/JPG)
2 Experience certificate from previous and current employer
(PDF/JPG)
3 Scan copy of Signature (JPG)
4 Scan copy of Passport Size photograph (JPG)

DECLARATION

I hereby declare that the information furnished above is true, complete and correct to the best of
my knowledge and belief. I understand that in the event of any of the information provided by
me are found false or incorrect at any stage, my candidature / appointment shall be liable for
cancellation / termination without notice or any compensation in lieu thereof.

Place: Signature of the Candidate

Date: