SRI VENKATESWARA INSTITUTE OF MEDICAL SCIENCES, TIRUPATI

NOTIFICATION Roc.No.C1/21/CfAR/SVIMS/18, Dtd.09.02.19

dtd.x Published in Andhra Jyothi, Dated 25.02.2019

APPLICATION FOR THE POST OF ___________________________________

1. Name of the Applicant (in Full) - (in capital letters) – (as per SSC certificate)
SURNAME – ONE SPACE GAP – NAME

2. Date of Birth: 3. Age (as on 01.07.2019): ____ YEARS____MONTHS____DAYS

D D M M Y Y Y Y

Affix Passport size

4. Sex: Male / Female : Photo attested by
Gazetted Officer
5. Category (Tick in the appropriate box) & Caste :________________ (write candidate name
and post applied for on
BC the backside of the
OC SC ST
A B C D E photograph)

6.
Address for communication Permanent Address

Mobile : Email:
Ph: Land line:

7. Qualifications (from S.S.C)

Year of Class/
S.No. Qualification College/Institution Board/University % of marks
Passing
(a). Academic:
1.

2.

3.

4.

(b). Technical:
Degree/PG Diploma/
Diploma/Certificate

(c). Any other Qualification:

Contd..2
 // 02 //

8. Registration details from the concerned Board in respect of Technical Qualifications:

a) Registration No.________________ b) Date: ________________

9. Details of experience:
Sl. Total
Name of the Institution Place Designation From To
No. Period

Total Experience:

DECLARATION

I do hereby certify that the particulars furnished above are true and correct to the best of
my knowledge. I also, declare that in the event of any information furnished in the application
and enclosures are found to be incorrect or false at a later date, my application may be rejected.

Date : Signature of the Applicant

Place : Name in full:
(in capital letters)

NOTE: Photostat copies of the following documents to be submitted along with the application
(with attestation from the Gazetted Officer)

1. Two Pass Port size photos in addition to the photo affixed on the application
(write candidate name and post applied for on the backside of the photographs)
2. Attested copy of SSC
3. Attested copy of Caste Certificate
4.Copies of all other Educational Qualifications
5.Copies of Experience Certificates from the concerned authorities along with
EPF/PF/CPS Annual statements with reference to the experience claimed as proof.
6.Copies of Registration details from the concerned Board/Council in support of 8th
point
7. Any other relevant certificates

LAST DATE FOR RECEIPT OF FILLED IN APPLICATION : 20-03-2019 5.00 P.M.

For further details contact phone numbers 0877-2287777, Ext. 2226.