Application Form For Other Specialties-TMC / TTCRC (: Affix Recent Passport Size Photograph

CONFIDENTIAL TATA MEDICAL CENTER, KOLKATA
14 MAR(E-W), New Town, Kolkata 700160

Telephone: 033-6605 7585
Application form for other Specialties- TMC / TTCRC

(Administration & Support Services, Research)
Position applied for

Affix recent
passport size
photograph
PERSONAL DATA
Name: Dr/Mr / Miss/ Mrs
Present address_________________________________________________________________________
City_________________________State_______________________Pin______________
Telephone ______________________________Mobile____________________________________________
Permanent address______________________________________________________________________
City_________________________State_______________________Pin______________
Telephone
______________________________Mobile_______________________________________________
Email __________________________________________________________________________
Date of birth:_________________________________________Gender : Male Female
Father’s Name & Occupation: ____________________________________________
Spouse’s Name & Occupation: ____________________________________________
Mother Tongue : _____________________ Other Language Spoken :_________________
Nationality ___________________________ Religion : __________________________
PAN No : _____________________________ AADHAR No. ____________________________

EDUCATIONAL QUALIFICATIONS (From Class X Onwards)
University Name of Session Exam Passed Marks Class /
Course / school/College From To Month / out Obtained percentage
Board Year Month
Explain breaks if any:_______________________________________________
Internship Details:
Period of Internship Start Date End Date
Name of the Institution, where

Internship is done
COMPUTER PROFICIENCY LANGUAGE PROFICIENCY
Packages & Languages Excellent Good Averag Languages Read Write Speak Understand
e
TRAINING DETAILS
Program Duration Year Organized by
EMPLOYMENT EXPERIENCE (Start from present employment)
Name and address of Period Position held Location Reasons for

organization From To leaving / break
Provident Fund Membership, if you are already a member of Employee Provident Fund :
(UAN):
MEMBERSHIP OF PROFESSIONAL BODIES.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PUBLICATIONS AND RESEARCH WORK (For Research Candidates): State only the numbers
Type of Publication Number of published Number of publications
or accepted as first author or
corresponding author
Original Research Papers in Indexed Journals
Other publications in Indexed Journals
Research Papers in Non-Indexed Journals
Text Books or Monographs or Thesis
Chapters in Text Books or Monographs
Abstracts in Indexed Journals
Unpublished abstracts presented at conferences
Describe (in 150 words) your most notable contribution in Research.

REFERENCES
Please provide the names, professional designations, business relationship and full mailing addresses, of three
references. Referees should have a good knowledge of your competencies, and must be familiar with your
work. One reference should be the current and immediate supervisor. Applicants who do not have work
experience must give recent academic references.
Name
Designation Work relationship
Address E-mail
Telephone (with STD / ISD code) Mobile
Name
Address E-mail
Telephone (with STD / ISD code) (mobile)
Name
Address E-mail
Telephone (with STD / ISD code) (mobile)
Current salary and benefits (per annum) Rs._______________________________________________

Notice required for joining the position if recruited ___________________________________________
Tentative Date of joining : ____________________________
GENERAL INFORMATION
1. Are any of your relatives employed by Tata Medical Centre? Yes No

If yes, specify Name_________________________________ Relation____________________________
2. Were you convicted in any criminal offence? Yes No If yes, give details
I hereby testify that the information provided by me in this application form is true and correct to the best of my
knowledge and belief. I accept that if any information is subsequently found to be false, I will be liable for
immediate disqualification or dismissal from service without any notice or liability occurring to the
organization.
Date
Place: Signature of the Applicant
List of documents attached to application:
1. School Leaving Certificate (Class X) [ ] YES [ ] NO

2. 10+2/ Graduate/Post Graduate Certificate [ ] YES [ ] NO
3. Professional Degree/Diploma Certificate [ ] YES [ ] NO
4. Experience Certificate: [ ] YES [ ] NO
5. Internship Completion Certificate, if applicable [ ] YES [ ] NO
6. PAN & AADHAR [ ] YES [ ] NO
_______________________________________________________________________________________
FOR OFFICE USE ONLY

_______________________________________________________________________________________
To be engaged from: Grade: Basic:
Function: Designation: Division:
Location: Induction Status: Trainee Probationer
Signature of the Head- Human Resources Signature of Divisional / Dept. Head

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CONFIDENTIAL TATA MEDICAL CENTER, KOLKATA

14 MAR(E-W), New Town, Kolkata 700160

Application form for other Specialties- TMC / TTCRC

Position applied for

Name: Dr/Mr / Miss/ Mrs

Date of birth:_________________________________________Gender : Male Female

Father’s Name & Occupation: ____________________________________________

Spouse’s Name & Occupation: ____________________________________________

Mother Tongue : _____________________ Other Language Spoken :_________________

Nationality ___________________________ Religion : __________________________

PAN No : _____________________________ AADHAR No. ____________________________

Explain breaks if any:_______________________________________________

Name of the Institution, where

COMPUTER PROFICIENCY LANGUAGE PROFICIENCY

Program Duration Year Organized by

EMPLOYMENT EXPERIENCE (Start from present employment)

Name and address of Period Position held Location Reasons for

MEMBERSHIP OF PROFESSIONAL BODIES.

Original Research Papers in Indexed Journals

Other publications in Indexed Journals

Research Papers in Non-Indexed Journals

Text Books or Monographs or Thesis

Chapters in Text Books or Monographs

Abstracts in Indexed Journals

Unpublished abstracts presented at conferences

Describe (in 150 words) your most notable contribution in Research.

Current salary and benefits (per annum) Rs._______________________________________________

1. Are any of your relatives employed by Tata Medical Centre? Yes No

1. School Leaving Certificate (Class X) [ ] YES [ ] NO

FOR OFFICE USE ONLY

Function: Designation: Division:

Location: Induction Status: Trainee Probationer

Signature of the Head- Human Resources Signature of Divisional / Dept. Head

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Mother Tongue : _____ Other Language Spoken :_

Nationality _ Religion :

PAN No : _ AADHAR No.