Application No. (For Office use only)
Application Format for Block ASHA Facilitator - 2017
| 1. Name of the candidate : | Applied for Sub-Division | Affix a Passport Size Photograph | ||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2. Father's/Husband's Name : | ||||||||||||||||||||||||
3. Date of Birth : ..... / ...... / ............. (DD/MM/YYYY) 4. Age as on 01.01.2017 : ______ 5. Gender : (Tick) : Male ( ) / Female ( )
6. Category Status : (Please Tick)
| UR | UR (EC) | UR (PH) | SC (EC) | ST | OBC-A | OBC-A (EC) |
|---|---|---|---|---|---|---|
- Permanent Address of Applicant :
- Present Address of Applicant :
- Academic Qualification : (H.S. & Onwards)
- Computer Literacy :
- Work Experience in Health Sector :
| Sl No. | Examination Passed | Board/Council/University | Year of Passing | Total Marks | Marks Obtained | Percentage of Marks |
|---|---|---|---|---|---|---|
| Degree / Course | Name of the Institution | Duration of Course | Total Marks | Marks Obtained | Percentage of Marks |
|---|---|---|---|---|---|
| Sl No. | Name of the Institution/ Organization | Designation | From (date) | To (date) | Duration of Experience |
|---|---|---|---|---|---|
DD No Amount
Date Details
14 DD
15. Enclosures: : (Tick in the brackets)
(a) Voter Card [ ], (b) Document of Age Proof (Birth Certificate/Admit card of Madhymaik or its equivalent / PAN Card/ Passport / Driving License [ ], (c) Mark Sheets of Higher Secondary or its equivalent [ ], (d ) Mark Sheets of Graduation [ ], (e) Mark Sheets of Master Degree [ ], (f) Computer Certificate [ ], (g) Proof Experience [ ], (h) Caste Certificate [ ], (i) Disability Certificate/ EC Certificate - wherever applicable [ ], (j) A Self-Addresses Envelope affixing Stamp of Rs.10/- [ ].
I do hereby declare that the particulars furnished above are correct.
Date : Place : Signature of Applicant
Important Dates
| Start Date | End Date | |
|---|---|---|
| Notification Issued | 21-Sep-2017 | |
| Applications | 22-Sep-2017 | 18-Oct-2017 |
Notification Issued By
- Organization : District Health and Family Welfare Samiti
- Organization City, State : hooghly, west bengal
- Organization Website :
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