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1

1 Applicant’s Name in full (in

Block Letters)

2 Father’s/Husband’s Name

3 Mother’s Name

4 Sex (Male/Female)

5 a) Date of Birth

(Date/Month/Year)

Both in figures & in words

b) Present Age (As on last

date of Application i.e.

12.08.2023

______ Years______ Months______ Days

Application No._____________/Roll No.______________

Date of Receipt_______________ (For Office Use Only)

ICMR-REGIONAL MEDICAL RESEARCH CENTRE

DIBRUGARH, LAHOWAL, ASSAM-786010, INDIA

APPLICATION FORM FOR TECHNICAL POSTS

ADVERTISMENT NO. 01/2023 DT.10/07/2023

Last Date of receipt of applications: 12th August 2023

Name of the Post ________________________________________________

ONLINE REGISTRATION NO. ____________________ (*Mandatory)

Space for

photograph

duly signed by

the candidate

Details of Application Fee: -

(Please note that SC/ST/PwBD/Women are Exempted)

(A). DD/IPO No.________________________________________

(B). Date ______________(C). Amount______________________

(D). Issuing Bank/Post office ______________________________

NOTE: -

1. APPLICATION FORM SHOULD BE FILLED IN CAPITAL LETTERS ONLY IN CANDIDATE’S OWN

HANDWRITING.

2. PLEASE GO THROUGH THE DETAILED VACANCY NOTICE BEFORE FILLING THE APPLICATION

FORM.

3. USE SEPARATE APPLICATION FORM AND FEE FOR EACH POST.

4. ALL FIELDS ARE MANDATORY. WRITE “NA” IF ANY CLAUSE IS NOT APPLICABLE OR NOT

RELEVANT TO THE CANDIDATE.

5. PLEASE SIGN ON ALL THE PAGES OF THE APPLICATION FORM.