application form

JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION AND RESEARCH, PUDUCHERRY – 605006.

DEPARTMENT OF NEPHROLOGY APPLICATION FOR THE POST OF PROJECT STAFF ‘A Multicenter, Randomized, Double-Blind, Placebo-Controlled, and Multiple Dose Study to Evaluate the Efficacy and Safety of VIS649 in Participants with Immunoglobulin a (IgA) Nephropathy (enVISion VIS649-201 study)’

1. Name of the Applicant : 2. Address with telephone no: and email id :

3. Nationality : 4. Post applied : Clinical trial coordinator/Pharmacist 5. Date of Birth :

Age:

6. Gender : M/F/others : 7. Educational Qualification :

Sl. No.

Qualification

Name of Institution& University

Years

No: of Attempt

Division/Grade /Aggregate percentage of marks

8. Professional /Research experience Sl. No.

Job title

Employer

Time

Brief description of job/ Responsibilities

9. Any other achievements you would like to mention 10. Have you ever been convicted by a court of law or is there any criminal case / disciplinary action / vigilance enquiry pending against you? If so, specify:

Declaration I _______________________________ hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. In the event of any information being found false or incorrect or ineligible and detected before or after Exam/Interview, I hereby convey my consent for cancellation of my candidature. Further, I declare I have gone through all the terms and conditions of appointment. I will abide the same and I will not claim any regularization.

Place: Date: