Affix recent

passport size
photograph duly
signed by the
candidate

APPLICATION FOR THE POST OF

(in Block letters)

Advertisement No.& Date

TO BE SUBMITTED TO:

The Director
National Institute of Mental Health & Neuro Sciences
P.B.No.2900, Hosur Road, Bengaluru - 560 029

Application fee particulars :

(Name & address of
branch, Transaction Details & Date Amount Name of the Bank & Address
date & amount etc.)

INSTRUCTIONS TO CANDIDATES:

a) The application form should be filled in by the candidate's own handwriting or typed b) All the
columns should be filled in and incomplete application will be rejected
c) Separate application should be sent for each post
d) Candidates who are in government service should apply through proper channel
e) Canvassing in any form will be a disqualification
f) Attested copies of educational certificates, experience certificates, age proof, caste/community certificates
and testimonials/references should be attached with the application.
g) If the space provided for furnishing particulars against Sl.No.1 to 27 is insufficient, full particulars may be
furnished in a separate sheet of paper and enclose with the application, inserting reference to that effect.

1. Full Name (in block letters)

2. Father's / Husband’s Name

Address & Occupation

Contd..2
 2

3. Mother's Name
& Occupation

4. Address for correspondence

(Contact Telephone/Mobile/Fax/E-Mail ID/

number with STD code)

5. Present Residential address

6. Permanent address

7. Date of Birth :

a) Age as on last date of submission of application

Years Months Days

8. Sex (Male/Female)

9. Marital Status
(Unmarried/Married/Widower/Widow/Divorce)

10. Nationality (by birth or by domicile)

11. Name of the State to which you belong

12. Religion

13. Whether belongs to SC/ST/OBC, if so specify the

category/community

14. Whether coming under Persons with Disability

category, if so whether :-
(i) Visually disabled
(ii) Orthopaedically disabled
(iii) Hearing disabled

Contd..3
 3

15. Whether Ex-serviceman, if so, particulars of

service.

16. Are you in-service candidate, if yes give

particulars of Dept/Designation/Date of
joining (Central/State/Autonomous organisation/
PSU/etc.)

17. Details of School/College/University studied

(Starting from SSLC/10th standard & onwards)

Name & address of the School/College Date of Date of Examination

joining leaving passed

18. Educational/Technical Qualifications

(Starting from SSLC/10th standard & onwards)

Examination Name of Institution/ Duration Date/month/ Class / Subjects studied

Passed Board / University of course year of passing Percentage

Contd..4
 4

19. Details of work experience (after possessing minimum required qualification for the post) :

Designation From To Organization Place Nature of work

20. Languages known to speak, read & write Speak Read Write

21. Knowledge of Hindi language

(Examinations passed)

22. Have you been a candidate for any post

advertised by this Institute, if so give
particulars and dates as to which post you
applied

23. References/Testimonials:
(from two responsible persons)
i) a) Name
b) Occupation
c) Address

ii) a) Name
b) Occupation
c) Address

24 . Have you been in abroad, if so give full

particulars:
a) Country/countries visited
b) Period of Stay
c) Date of return to India
d) Purpose of visit

Contd..5
 5

25. Have you done any post graduate work or

published any papers & papers presented at
conferences, if so give full particulars.

a) Publications :
(Journals / Papers / Chapters in Books / Books)
(Please mention the numbers in figures )

National
(i) Peer reviewed :
(ii) Non peer reviewed :
(iii) Others :

International
(i) Peer reviewed :
(ii) Non peer reviewed :
(iii) Others :

b) Papers presented: (at conferences)

National :

International :
(Please see the Annexure)

c) Honour’s & Medals :

26. Any other relevant information

27. List of enclosures

i) I, hereby declare that, all the above particulars furnished by me is true to the best of my knowledge & belief.
ii) I am aware that, my application is liable to be rejected if the particulars given is incomplete or found to be incorrect.

Signature of the candidate

Place:
Date :

Contd..6
 6

NO OBJECTION CERTIFICATE FROM THE PRESENT EMPLOYER

Ref. No: ………………………………………….. Date: ……………………

Certified that Shri./Smt./Kum. _

is a permanent / temporary employee of this Institute / Organisation / PSU / Govt. Office in the

designation of since

(Date) . His/her application is recommended and forwarded for the post. This

Institute / Organisation / PSU / Government Office has no objection for applying/attending any

interview to the post and he/she would be relieved in the event of selection.

Signature

Designation

(Head of the Organisation with office seal)

Place:

Date :
 APPLICANT BANK ACCOUNT DETAIL FORM

NAME OF THE APPLICANT

POST TO WHICH APPLIED

BASIC DETAILS

CITY / POSTAL CODE

DISTRICT

STATE

COUNTRY

ACCOUNT HOLDER NAME

BANK NAME
BANK DETAILS

BANK ACCOUNT NUMBER

BANK IFSC CODE

CORRESPONDENCE ADDRESS

CONTACT
DETAILS EMAIL ID

MOBILE NUMBER

1) I hereby declare that, all the above particulars furnished by me are true to the best of my knowledge & belief.
2) I am aware that, my application is liable to be rejected if the particulars given are incomplete or found to be incorrect.

Applicant Signature
PAYMENT DETAILS MADE BY THE CANDIDATE

NAME OF THE APPLICANT

POST APPLIED FOR

a) Digital Payment
MODE OF PAYMENT b) BHIM App
c) Debit Card
d) Credit Card
e) Wallet
f) IMPS
g) Net Banking
h) Others -……………..

Kindly choose the above option.

TRANSACTION ID / REF NO
.

DRAWN ON BANK

DATE OF PAYMENT

AMOUNT

REMITTANCE/ TRANSACTION COPY ENCLOSED

REMARKS

1) I hereby declare that, all the above particulars furnished by me are true to the best of my knowledge & belief.
2) I am aware that, my application is liable to be rejected if the particulars given are incomplete or found to be incorrect.

Applicant Signature
 ANNEXURE

NAME OF THE CANDIDATE:

POST FOR WHICH APPLIED:

DETAILS OF PUBLICATIONS:

1. Peer reviewed journals:

a) International No.:

Author

Name of the article

Name of the journal

Year of Publication

b) National No.:

Author

Name of the article

Name of the journal

Year of publication

Cond..2/-
 -:2:-

2. Chapters in Books

Name of the article:

Name of the editor

Name of the book

Name of the Publisher

Year of Publication

3. Books

Name of the author

Name of the book

Cond..3/-
 -:3:-

Name of the publisher

Year of publication

Signature of the candidate.