FORM - 17

TEQ PROFORMA (FOR CIVIL)

Application for the Post of …………………………..in the department of.............................

Name of the Candidate: ___________________________________

Date of Birth & Age: ___________________________________
A. For MD/MS/DM/M.Ch candidates
Qualification Name of the Medical Year Registration Name of the Annexure
College & Univ. * No. of UG & State No.
PG with date Medical
Council
MBBS

MD/MS

DM/M.Ch.

B. For DNB Candidates

Provide Bedded information for non-teaching hospital with documentary evidence
Qualification Name of Medical Year Registration Name of the Annexure
College/Institution/ No. of UG & State No.
Hospital * PG with date Medical
Council
MBBS

DNB

DrNB

C. For Non – Medical Candidates

Qualification Name of the Medical Year Registration Name of the Annexure
College & Univ. * No. of UG & State Medical No.
PG with date Council
M.Sc. in Medical

Ph.D. in Medical

D. Training Course from Institutions designated by NMC

Annexure
No
Certificate of Basic Course in Medical Education Technology Yes No
Certificate of Basic Course in Bio-Medical Research Yes No
*Mandatory with documentary evidence
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Note: For PG & Post PG qualification additional Registration certificate particulars be furnished
and subject name be furnished within the bracket after scoring out whichever is not
applicable.
Copies of all Registration Certificates attached.

Present Designation: _____________________________________

Department: ___________________________________________

College: ___________________________________________

City: ___________________________________________

Nature of appointment: Permanent/Temporary/Adhoc/Honorary/Part-time

Address:-
……………………………………………………………………………………………

………………………………………………………………………………………………

Mobile No:-…………………………….

E-mail ID:- …………………………….

Date of joining present institution:- _______________________ as ________________

Details of the previous appointments/teaching experience:-

Position Name of College/ Recognized/ From To Total Annexure
Institution Not Experience No
Recognized/ in year
LOP
Tutor/
Demonstrator/
Registrar
Sr. Resident
Assistant
Professor

Associate
Professor

Professor

Details of the Research publication in indexed/national journals:-

S.No. *Topic First/Corr. *Name of *Name of *Date of Annexure
Author journals with Indexing Acceptance/ No
ISSN No. agency Publication

* Mandatory with documentary evidence

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It is declared that each statement and/or contents of this declaration made by the
undersigned are absolutely true and correct. In the event of any statement made in this
declaration subsequently turning out to be incorrect or false the undersigned has
understood and accepted that such misdeclaration in respect to any content of this
declaration shall also be treated as a gross misconduct thereby rendering the undersigned
liable for necessary disciplinary action (including removal of his/her name from Indian
Medical Register).

(Signature of the Candidate)

Date:

Place:

Endorsement
(*Endorsement by Colloge/Institute is not mandatory if the applicant is not working
in any Medical College presently).
This endorsement is the certification that the undersigned has satisfied
himself/herself about the correctness and veracity of each content of this declaration and
endorses the abovementioned declaration as true and correct. In the event of this
declaration turning out to be either incorrect or any part of this declaration subsequently
turning out to be incorrect or false it is understood and accepted that the undersigned
shall also be equally responsible besides the declarant himself/herself for any such
misdeclaration or misstatement.

(Countersigned by the Director/Dean/Principal)

Date:

Place:
 FORM - 17

TEQ PROFORMA (FOR ARMY)

Name of the Candidate: ________________________________________ Date of Birth & Age: ___________________________________

Mobile No………………………………………………E-mail ID:………………………………………………………………………….………..
Address:…………………………………………………………………………………………………………………………………………………

Qualification College & Univ. Year Registration No. of UG & PG with date Name of the State Medical Council
MBBS
MD/MS/
DM/M.Ch.
( )
Experience
Sl. Department Details of Experience with date and place (*)
No.
Graded Specialist Classified Specialist Adviser/Consultant
Period Place of posting Period Place of posting Period Place of posting
From….. From…… From..….
To…… To…… To……

Teaching
Experience
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Total teaching experience___________

* Mandatory with documentary evidence

It is declared that each statement and/or contents of this declaration made by the undersigned are absolutely true and correct. In the event of any
statement made in this declaration subsequently turning out to be incorrect or false the undersigned has understood and accepted that such mis-declaration
in respect to any content of this declaration shall also be treated as a gross misconduct thereby rendering the undersigned liable for necessary disciplinary
action (including removal of his/her name from Indian Medical Register).

(Signature of the Candidate)

Date:
Place:

Endorsement
This endorsement is the certification that the undersigned has satisfied himself/herself about the correctness and veracity of each content of this
declaration and endorses the abovementioned declaration as true and correct. In the event of this declaration turning out to be either incorrect or any part
of this declaration subsequently turning out to be incorrect or false it is understood and accepted that the undersigned shall also be equally responsible
besides the declarant himself/herself for any such mis-declaration or misstatement.

(Countersigned by the Director/Dean/Principal)

Date:
Place:
 FORM - 17

CHECK LIST (for submission of documents)

The candidates are requested to ensure that the documents be enclosed as per the order in
the Checklist. All papers/documents should be numbered according to the checklist.
Please arrange the application in the following order & tick mark the relevant boxes:

1. Online Payment of Rs. 5000/- (Rupees Five Thousand only) + 18% GST i.e Yes No
total amount of Rs. 5900/- through RTGS/NEFT/IMPS in favour of
Secretary, National Medical Commission, Canara Bank Account No.
90682160000025, IFSC Code. CNRB0019109, Sector-12A, Dwarka
Branch New Delhi-110078 and intimate us the UTR No. after payment for
further processing of application………….………………………………..

2. Application form …………………………………………………………… Yes No

3. Copy of educational/academic qualification certificates …………………… Yes No

4. Copy of teaching experience certificates ……………………….…………. Yes No

Yes No
5. Copy of Original Research Publications with acceptance letter..………….

6. All documents will be self-attested……………………………………….. Yes No

Signature:- _______________________
Dated:- _________________________
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NATIONAL MEDICAL COMMISSION

Pocket - 14, Sector - 8, Phase-I, Dw arka, New Delhi - 110 077
Phone : 011 -25367033,25367035, 25367036,
Email : [email protected], Website : http://www .nmc.org.in

ACKNOWLEDGEMENT
--------------------------------------------------------
(to be filled by the candidate)

Received Application from Ms/ Mr.………………………………………… D/o / S/o

Sh………………………………………………with UTR No……………………………
dated..……………………… for Rs ………………………. for consideration of eligibility as
TEQ Regulations, 1998 for the post of Assistant Professor/Associate
Professor/Professor.

OFFICIAL Signature of Receiving Official

SEAL
with date