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Maharashtra University of Health Sciences, Nashik

Mhasrul , Dindori Road, Nashik – 422 004

APPLICATION FOR RECOGNITON AS POST – GRADUATE TEACHER FOR HEALTH

SCIENCE COURSE

1. Applicants Full Name in CAPITAL :

(Beginning with Surname)
.
Name and address of the College / Institute:

Phone No . Fax No . ………… Email ID :

Date of joining the College / Institute :

2. Residential Address : Residential Ph . No .(if any ) : -

Date of Birth : Age: . Date of Retirement :

3. Registration Number and Date

U.G :
P.G :
4. Designation and exact position of the applicant on the teaching staff of the College /
Institute in which he is working showing its relation to the staff general and whether
his appointment is approval by the University (if approved enclose a certified Xerox
copy of the approval )
-

5. Full Time / Part time / Honorary :

6. The Degree or Diploma course (s) and subject (with Branch (es) if any ) for which the
applicant desired to be recognised :
-

7. Particulars of the Degree and the subjects in which applicant is already recognised
as a Post Graduate teacher of any University and date of recognition .

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8. Educational qualification : Degree / Diploma / Ph. D. etc.

Degree/Diploma/ Name of the University Year of Class Wheather

Ph.D. Passing Obtained recognized by
central Council
 M.B.B.S.
M.D.

9. Title of thesis / Dissertation or published work for which the Master’s Degree was /
were a
10. Books and Research publications including Articles embodying the results of
research or investigations,published in recognized journals. Work done subsequent
to the award of the research degree should be specifically indicated (Attach details)

11. Branch of the subject in which applicant has specialized with details of specialization.
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12. Teaching Experience :
The Designation University College / Subject Total Teaching
classes Institute Experience
taught by UG Level PG
applicant Level
Degree In
First year

Second .
year
Third year
Fourth year

Post
Graduate
( if any)

13. Complete statement of the actual teaching work at he present being done.
Periods of Lectures per week : ..… of……………. duration … …classes
Periods of Seminars per week : ..… ……… of……………. duration … …classes
Periods of Tutorials per week : ..………… of……………. duration ……classes
Periods of Laboratory per week : ..… ……… of…… …… duration …classes
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Supervision
14. a) The Institute at which the applicant proposes to guide research or teach
………….
b) The details as to the facilities available for the purpose (e.g. Library / Laboratory /
Equipment / Hospital / Ward)

c) Whether the Institute / Department is approved by the University or otherwise

--------.
15. The exact position of the applicant on the teaching staff.
 Name of the Head of the Dept. (Give names of the other teachers in the Dept.in
order of seniority and whether they are recognized.

16. Subject and faculty in which recognition is to be sought.

Subject - ………………… Faculty - ………………

I hereby declared that the information given in the application as it relates to me is

true and correct.

Place - Miraj
Date - / / 2010 Signature of Applicant
To be submitted through the Head of the Department and Institute.

Date - / / 2010 Signature of Head of the Department

Of the subject in the college / Institute

Date - / / 2010 Signature of Dean / Principal

Stamp of the College / Institution

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List of Relevant Documents Required for the purpose of Recognition

1) Previous University PG Recognition Letter.

2) University UG approval.
3) Age Proof Certificate.
4) Change of Name Certificate ( If applicable)
5) UG, PG degree Certificate.
6) Registration Certificate.
7) Experience Certificate Signed by Dean / Principal.
8) Appointment letter.
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