APPLICATION FOR THE POST OF MEDICAL OFFICER ON CONTRACT BASIS

Advt. No : E/HR/OHC/1/2017 dated ____________

Paste self attested recent passport size photograph

Name (IN BLOCK LETTERS)

Gender

Fathers Name

Mothers Name

Date of Birth

a)___________________ Age as on 01.11.2017

b)___________________

6.

State of Domicile and Nationality Contact / Mailing Address

Permanent Address

7.

Pin Code ----------------------Pin Code ----------------------Phone No.(with STD Code) : Phone No.(with STD Code) : Mobile No : Mobile No : Email ID : Email ID :

Religion

Category SC /ST /OBC /GEN

10.

Are you a Person with Disability (PWD)/ If

Yes /No so, mention the category of Disability (VD/OD/HD)(copy of the Certificate to be

VH/OH/HH produced at the time of interview)

11.

Are you an Ex-Serviceman?

Yes /No

-2

12. EDUCATIONAL QUALIFICATION: (Academic and Professional)

Sl. No.	Name of Qualification with Specialization wherever applicable	Institution / University	Nature of the Course (Full Time/Part Time/ Correspondence	Duration of the Course	Subjects / Specialization	Class/ Divn.	% of Marks (Aggre -gate of all years)	Month & Year of Passing

(Note : Please give full & complete information. Use separate sheets if required)

13. Post Qualification Experience :

Name of Organization	Post Held	From (dd/mm/yyyy)	To dd/mm/yyyy)	Experience in brief
Total Experience in Years & Months =

(Note : Please give complete details for the experience profile like Date, Month & Year. Use separate sheets if required)

1. MBBS Registration No.:______________________________________ Date _________________
   
   
2. If selected, how soon can you join ? : _______________________________________________
   
   

I hereby declare that the above statements are true and complete to the best of my knowledge and belief. I understand that in the event the information is found to be false or incorrect, my candidature/ appointment may be considered as terminated without any notice.

Place :

Date : Signature of the Candidate

Note : The candidate is required to fill in all the columns.