ICMR - NATIONAL CENTRE FOR DISEASE INFORMATICS AND RESEARCH
Department of Health Research,
(Ministry of Health & Family Welfare),
II Floor of Nirmal Bhawan, ICMR Complex,
Poojanahalli Road, Off NH-7,
Adjacent to Trumpet Flyover of BIAL, Kannamangala Post, Bangalore - 562 110. India.
(APPLICATION FORM for Economically Weaker Sections Category)
Note : All answers must be given in words and not by dashes and dots
No columns should be left blank
Name of the post applied for *
Projects
Select Projects in order of preference
Name of the Institute / Centre 
Personal Inforation
1. Name in Full: (IN CAPITAL LETTERS) *
2. Address:(i)  Present:*
City*
State
Pincode*
(ii) Permanent:
City
State
Pincode
(iii) Contact Telephone No. Mobile *
(iv) Email address:*
3. Date of Birth: *   (dd/mm/yyyy) Gender*
4. Marital Status: * Nationality
5. Religion *
6. (a) Are you a member of EWS
(Answer: Yes or No):*
If Yes, Select one option
If the answer is Yes, Give EWS details
    (b) Are you Physaically Handicapped
    (If yes then % of Disability)
Educational Details
7. Particulars of all examinations passed and degree and technical qualifications obtained (Commencing with the Matriculation or equivalent examinations). Attach attested copies of all certificates.)*
Examination or Degree obtained Class or Division Subject taken Date of Passing Grade / Percentage
8. What language (excluding Indian languages) as you read or speak. State any examination passed in each:
Language Read only Speak only Read and speak Examination passed
 
Work and Publication Details
9.Details of postgraduate work / publications 
Number of Publications 
9.2. Papers in Books, Proceedings & non indexed journals
10. Total Experience with details in each area:
11. Major academic / other achievements:
12. Awards and prizes received: (Name of Awards / Fellowship, year, awarded by)
13. National / International Conferences/Seminars etc. attended:
(List with title of papers presented, if any)
14. Membership of National and Internation Bodies-:
National :
International:
Experience Summary
15. Give particulars of Employments held in chronological order:
Select for Current Working Name of employer & address Date of joining
(dd/mm/yyyy)		 Date of leaving
(dd/mm/yyyy)		 Designation & Nature of work performed Salary(excluding allowances) last drawn & scale of pay Experience
 Year Month
 
16. Copies of testimonials
1.
2.
3.
4.
5.
16. Information relevant to the applicant may be mentioned here.
17. Has the candidate applied earlier for any post in the Council or elsewhere? If so,give details.
18. If selected, What notice would you require before joining?
Reference Detail
19. References
(The should be persons resident of India and holders of responsible position. The should be intimately acquainted with the applicant's character and work, but must not be relatives. Where the candidate has been in employment, he would either give his present or most recent employer or immediate superior as a reference or produce testimonials from him in regard to the candidate's fitness for the post for which he is an applicant).
1 Name
Occupation or position
Address
2  Name
Occupation or position
Address
3 Name
Occupation or position
Address
Declaration
1. I hereby declare that the entries in this form and the additional particulars, if any, furnished herewith are true to the best of my knowledge and belief.
2. I have informed my Head of Office/Department in writing that i am applying for this post and shall produce "No objection" certificate at the time of the interview.
Place
Date (dd/mm/yyyy)