INTEGRAL COACH FACTORY, CHENNAI – 600 038

Notification No PB/RR/39/Contract/PT/03/2019
Application form for Physiotherapist & Pharmacist on Contract Basis
(Read the instructions carefully before you start filling up the application form)

Physiotherapist Pharmacist

Tick relevant box as applicable

Affix your recent
1. Name of the Candidate :
passport photo-
(in Capital letters)
graph duly self
attested
2. Father’s Name :

3. i) Address :

ii) Mobile No.* :

*mandatory

iii) email-id :

iv) Aadhaar No.* :

*mandatory
DD MM YYYY
4. Date of Birth (As per matriculation certificate) :

5. Age (as on 01/01/2020) : …………Years

6. Sex (M/F/Others) : …………………

7. Nationality : …….…………..

8. Community (SC/ST/General) …..………

(to be attached)
9. Personal Marks of Identification (To be filled compulsorily)

(a)…………………………………………………………………………………

(b)…………………………………………………………………………………

10.Educational Qualifications:
(Self attested marksheets/certificates to be attached)

Sl.No. Year Exam passed

11. Previous experience in the post applied for

(a) Physiotherapist—Desired experience of 2 years in Physiotherapy from a Govt/Pvt Hospital with

Atleast 100 beds. (Relevant certificate to be attached)

(b) Pharmacist — Should be registered as Pharmacist under the Pharmacy Act 1948
(Certificate to be attached)

Year
Sl.No Name of the Hospital Department
From To

I hereby declare that all the particulars given in this application are true & correct to the best of
my knowledge & belief, If anything is found incorrect or false, the application is liable to be re-
jected and if the mistake is detected after my selection my service is liable to be terminated. I
hereby declare that I will abide by all conditions stipulated.

Note : Self attested photocopies of the following documents should be enclosed

i) Proof of Date of birth (birth certificate)

ii) Educational Certificates
iii) Aadhaar Card & PAN Card
iv) Experience Certificate
v) Community Certificate (SC/ST/EWS)
vi) Transfer Certificate/School Leaving Certificate
vii) Application Fee Rs.500/- or Rs.250/-

Place:
Signature of the Candidate
(Left Hand Thumb Impression) Signature in Capitals will be REJECTED
Date: