6.. TheIn-Charge,ITCell,WBSH& FWSamiti,SwasthyaBhawan,Kol-91with arequesttoupload thesameinthewebsitewww.wbhealth.gov.in forwidecirculation

7. TheDPC(RNTCP),DakshinDinajpur

APPLICATIONFORMATFORTHEPOSTOF _

To, Affix one color

The Chief Medical Officer of Health & Member Secretary, recent passport

District Health & Family Welfare Samity, Dakshin Dinajpur.

size photo here

Sir, I, ,liketoapplymyselfasacandidateforthepostof as per Recruitment Notice No. ___________________ given in the website & according to the terms of reference.

MY BIO-DATAGIVENASBELOW: SL.NO. I PARTICULARS INFORMATION

1. I Name of the Candidate (in block letters)
   
   
2. I Father's/Husband's Name (in block letters)
   
   

Full address with Pin code

3.

Phone No.

1. IWhether belongstoSC/ST/Others
   
   
2. I Date of Birth (DD/MM/YYYY)
   
   

1. a) IAgeason01/01/2017 (writeyearsmonths &days)
   
   
2. I Academic qualification achieved Without Additional Marks
   
   

51. No.	Exam(s) Passed	Board/University		Full Marks	I	Marks Obtained	% of Marks	Year of passing		Major Subjects
i)
ii)
iii)
iv)
7.	I Duration of course completed in computer
8.	I Driving License No. (wherever applicable)
9.	I Duration of Experience in TB/ other health related activities
10.	Demand Draft No.		Date				Amount		(Rs.)

Contd.....

Iam enclosing the following supporting documents (Self attested photocopy):

1.

4.

5.

9.

10.

-DECLARATION-

I, do hereby solemnly declaring that the above informations

I

given by me are correct to the best of my knowledge and belief. I know that any information given above by me, if found incorrect at any time, my candidature will be cancelled immediately.

Date:

Place:

Full Signature of the Candidates