This document is a proforma for candidates applying for teaching posts at the Raichur Institute of Medical Sciences in Raichur. It requests information such as the candidate's name, contact details, date of birth, education history including degrees earned and marks obtained, teaching experience, publications, and extracurricular activities. Candidates are asked to submit recent photos, degree certificates, medical registration copies, experience certificates, and a PAN card along with the completed proforma. Space is provided at the end for remarks by the verifying officer.

1. RAICHUR INSTITUTE OF MEDICAL SCIENCES, RAICHUR
PROFORMA FOR TEACHING POSTS
Details to be furnished by candidates who appear for
Walk - in – Interview on 11.08.2014 at RIMS Raichur
1. Name and address of the
candidate with Telephone no. /
Mobile no
:
2. Post applied for :
3. Department :
4. Date of Birth as mentioned in SSLC
marks card
:
5. Age :
6. Category (GM/SC/ST/Cat-I/ 2A/
2B/3A/3B)
:
7. Date of passing MBBS & University :
8. Marks Secured in MBBS : University Maximum
Marks
Marks
Obtained
Percentage
I – MBBS (Phase I) :
II – MBBS (Phase II) :
III – MBBS (Phase III, Part-I) :
III – MBBS (Phase III, Part-II) :
TOTAL
: University Maximum
Marks
Marks
Obtained
Percentage
9.
Date of passing of PG Diploma
course, University and details of
marks
:
10.
Date of passing of PG Degree
course , University and details of
marks
:
11. Additional Qualification if any :
a) Gold Medal :
b) Sports :
12.
Date of passing super specialty
course , university & details of
marks
:
13. Details of Publications :
14. Extra Curricular Activities :
15.
Presently working in
(Name of the Institution & place)
:

2. 16. Particulars of teaching experience :
Sl.No. Designation
Name of the
Institution
From To Total experience
Total Teaching Experience
17. Please enclose the copies of : Recent Passport size photo’s – 2 Nos. Yes / No
: Copies of Degree certificates of MBBS and
PG degree.
Yes / No
Copies of Medical Council Registration of
UG and PG Degree
Yes / No
: Experience certificates of all previous
teaching appointments including the
present institution.
Yes / No
: PAN Card Yes / No
18. Other information if any , please
specify
:
Date :
Place :
Signature of the Candidate
For Officer Use Only
Remarks by the verifying Officer :
a)
b)
c)
d)
e)
f)
Signature of the Verification Officer
Director
Raichur Institute of Medical Science
Raichur