Institute of Psychiatry and Human Behaviour Pharmacist Recruitment

Entry Serial No:_______________ Received Date:_______________ COMMON APPLICATION FORM IN THE INSTITUTE OF PSYCHIATRY & HUMAN BEHAVIOUR , BAMBOLIM, GOA-403202.

To, The Director, Institute Of Psychiatry & Human Behaviour , Opp. Holy Cross Shrine, Bambolim, Goa-403202.

PHOTO SELF ATTESTED

Subject: Application for the post of ________________________________. [

Sir, With reference to advertisement in local news paper ___________________ dated___________, I hereby apply for the post of _________________________ in the Institute of Psychiatry & Human Behaviour , Bambolim, Goa. My Bio-data is as under: a) Name: _______________________________________________________ (in capital letter)

NAME

MIDDLE NAME

SURNAME

b) Father’s/Husband Name: _____________________________________ c) Address:

Door No. ___________ Location __________________ Village/Town _____________ Taluka _______________ Constituency ________________ District ___________ State __________________ Pin. ___________________

d) Whether posses required qualification: Yes / No. e) Category: ____________. f) Date of Birth : Day/ _______ Month/ _______Year ___________. g) WhatsApp Contact No. _______________________ h) E-mail ID: __________________________________

i) Valid employment Registration Number and Date: __________________________________________ j) Number and date of valid 15 years Residential Certificate at Goa :__________________________________ k) Valid Caste Certificate Number and Date: ___________________________

DECLARATION I

________________________________________________

son/daughter/wife of __________________________ hereby state that, the contents of the application are true to my own knowledge and I declare that, I possess the requisite essential qualification and other mandatory documents for the post. I understand that in the event of particulars or information given herein being found false or incorrect, my candidature for the recruitment is liable to be REJECTED OR CANCELLED EVER AFTER SELECTION. Yours faithfully,

(___________________________) Signature of the applicant with full name