APPEAL FORMAT FOR INCLUSION OF PARTICULARS BY INDIVIDUALS

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TO UPDATE IN CML 2010

1	Name
2	Sex
3	Present Designation
4	Present Station
5	D.O.B.
6	Date of joining service
7	Whether selected by TNPSC (if yes) state the year and seniority)
8	Date of regularization
9	Date of declaration of probation
10	CML/ 2005/2009 as per recent publication in www.tnhealth.org
11	Whether selected by 10a1/ Contract/ Compulsory PG postings/ CEmONC /TNHSP
12	If yes, please state if regularized by special TNPSC exam
13	If regularized, please state the date of passing the exam and the seniority number in the exam
14	Community (state OC/ BC/ MBC/ SC/ ST)
15	e-mail address
16	Mobile number
17	Office phone number (with code)
18	Tamilnadu Medical Council registration Number
19	QUALIFICATIONS:		DATE OF PASSING
20	MBBS
	Diploma
	Degree
	Super specialty
21	Any Disciplinary Proceedings pending
	Say Yes or No
	If yes (furnish details)
22	Whether relinquished any promotion. If yes date of relinquishment
23	Designation as on 1.1.2006
24	Designation as on 1.1.2009
25	Unauthorised absence (please specify the period)
26	Remarks

Declaration

I hereby declare that the above details are true to the best of my knowledge and as per service records.

 Date:         
                                                                                                 (Signature of the individual)



Checked and countersigned


DEAN / JDHS /DDHS/ RAMO / HS (ESI)/
With office seal

Note: Please send above format by a typed copy through E_mail and Post.
      <dmrhs.tn@rediffmail.com>       <suri_1971@yahoo.com>