19JJHGIK JAQ= 1@GKG?I9H@ G> K@= - KEM …...November, 16, 2016 Recruitment of Pharmacovigilance Associate Under Pharmacovigilance Programme of India (PvPl) At Seth GSMC &KEM Hospital

Post applied for Location (office) (as per table) _

PROFORMA FOR APPLICATION

Father's NamePassport size

Photograph of the

candidate

Date of Birth

Mother's Name

Marital Status

Proficiency in Languages

Address for Correspondence

Telephone No. (O), (R), (M)

Present

Permanent

Educational Qualification

Degree/ Year Board/ Subjects/ % of

Examinations University Specialization marks

Proficiency in computer Details of course/training undertaken

Experience

Declaration

I hereby declare that the information given above is true to the best of my knowledge and belief

and nothing has been suppressed there of.

Signature

Date

Place