Application Form for post of Vaccine Cold Chain Manager under NHM, Gujarat
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Attach recent photograph here
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Note: Please fill all the information completely. Type or Print in dark ink. All the relevant informaon should be included on this form.
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Do not write in this space Application Received Date :____/____/______
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Date of Application: ____/____/_______
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Surname: ______________________
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First Name: ______________
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Maiden name: _______________
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Sex: M/F _____________
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Nationality: ____________
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Date of Birth: ____/___/______
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Current Address:
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Permanent Address:
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Telephone/Mobile: 1.) 2.)
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Email:
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Education Qualification: (Graduation and Above )
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Institution/University
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From Month/Year
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To Month/Year
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Name Degrees
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Final Year's Percentage
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Attempt in Final Year
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Experience: (in completed years)
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Health/ Hospital / Pharmaceutical Sector : ____________________________ Years
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Preferred Location: (Any 5 out of Banaskantha, Narmada, Tapi, Dang, Rajkot, Dewbhumi Dwarka, GirSomnath and Rajkot Municipal Corporation) 1._____________________________ 2.______________________________ 3.____________________________ 4._____________________________ 5.____________________________
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I certify that the information I have provided in the present information is true, complete and correct to the best of my knowledge. Any discrepancy will attaract disqualification. Place:___________________________ Date:____________________________ Signature:___________________________
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