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 BID-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)
   
   

Fulladdresswith Pincode

3.

Phone No.

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

1. a) IAgeason01/01/2018 (writeyearsmonths &days)
   
   
2. I Academic qualification achieved Without Additional Marks
   
   

Exam(s) Year of Major

SI.No. Board/University Full I Marks

Passed % of Marks passing Subjects

Marks Obtained

n

ii) iii) iv)

1. I Duration of course completed in computer
   
   
2. IDrivingLicenseNo. (whereverapplicable)
   
   
3. IDurationofExperienceinTB/otherhealthrelatedactivities
   
   
4. Demand Draft No. Date Amount (Rs.)
   
   

Contd.....

Iamenclosingthefollowingsupporting documents(Selfattestedphotocopy):

6.
7.
8.
.J
9.		.	...,.
10.
	-DECLARATION-

I, / do hereby solemnly declaring that the above informations 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 atanytime, mycandidature will becancelledimmediately.

Date:

Place:

Full Signature of the Candidates

	Start Date	End Date
Notification Issued		19-Jan-2018
Interviews		02-Jan-2018

• Organization : District Health and Family Welfare Samiti
• Organization City, State : dakshin dinajpur, west bengal
• Organization Website : www.wbhealth.gov.in/recruitment