VENUE AND DATE OF WALK-IN INTERVIEW :

Eligible and willing candidates should report as per details given below along with the original academic, professional and experience certificates with one additional self attested copies of all the testimonials, two passport size photographs. SC, ST and OBC candidates should bring their latest caste certificate issued by the Competent Authority in the prescribed format.

Encl: Application format.

(R. B. Jena)

Dy. Chief Personnel Officer (Gaz.) For Principal Chief Personnel Officer

APPLICATION FORMAT

APPLICATION FOR ENGAGEMENT OF PART TIME DENTAL SURGEON AT

1. Name of the Candidate (in Block Letters) :

2. Fathers/Husbands Name :

1. Postal Address: (with contact No.) :
   
   
2. Permanent Address ( with Tele/Mobile No.) :
   
   
3. Present Occupation:
   
   
4. Date of Birth (in figure and words):
   
   
5. Category to which he/she belongs: (UR/SC/ST/OBC)
   
   
6. Nationality:
   
   
7. Educational/Professional Qualifications
   
   
8. Registration Number of Medical Council and State:
   
   
9. Experience if any:
   
   
   1. Enclosures : (self attested)
      
      
      1. Two recent Passport size photographs
         
         
      2. Certificate indicating the Date of Birth
         
         
      3. BDS/Post Graduate Degree Certificate.
         
         
      4. Internship Certificate
         
         
      5. Registration Certificate
         
         
      6. Certificate in support of community in case of SC/ST/OBC candidates issued by competent authority.
         
         
      7. Certificate of experience, if any
         
         

(N.B : -Please bring originals for verification at the time of Interview.)

13 I, hereby declare that all statement made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any of the particulars or information given herein being found false or incorrect or in the event of misstatement or discrepancy in the particulars being detected at any stage before or after my appointment, my contract is liable to be terminated forthwith independent of any civil or criminal legal action. I understand that I am not eligible for any TA/DA/accommodation for this interview.

Place :

Date : Signature of the Candidate Name of the Candidate______________