NATIONAL CENTRE FOR DISEASE INFORMATICS AND RESEARCH
INDIAN COUNCIL OF MEDICAL 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
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 Scheduled Caste
(Answer: Yes or No):*
If Yes, Select one option
If the answer is Yes,Give Caste
    (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 Specialization/Subject Date of Passing Grade / Percentage
8. Software Skills
9. Total Research Experience with details in each area:
10. Major academic / other achievements:
11. If selected, What notice would you require before joining?
Experience Summary
12. 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 Salary(excluding allowances) last drawn & scale of pay Experience
 Year Month
 
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)