Scribd
Upload
56 views2 pages

Aplication

This document is an application form for recruitment to the post of [position] on a contract basis in the National Health Mission of East Godavari District. The 3-page form requests information such as the applicant's name, father/husband's name, gender, date of birth, religion, social status, qualifications, experience, address and a declaration signed by the applicant. It also includes a verification checklist to confirm that required supporting documents like caste certificate, experience certificate, and qualification certificates have been provided.

Uploaded by

Dattatreya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
56 views2 pages

Aplication

This document is an application form for recruitment to the post of [position] on a contract basis in the National Health Mission of East Godavari District. The 3-page form requests information such as the applicant's name, father/husband's name, gender, date of birth, religion, social status, qualifications, experience, address and a declaration signed by the applicant. It also includes a verification checklist to confirm that required supporting documents like caste certificate, experience certificate, and qualification certificates have been provided.

Uploaded by

Dattatreya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

ANNEXURE-II

NATIONALHEALTHMISSIONEASTGODAVARIDISTRICT
RECRUITMENT NATIONAL HEALTH MISSION)-2023

APPLICATIONFORTHEPOSTOF (ONCONTRACTBASIS)
(Application should be downloaded and submitted in A4 size paper only)

Notification No.07/2023. Application No……………………. (for office use only)

1)Name of the applicant


(in BLOCK letters)
2)Father’s Name/Husband’s
Name
3)Gender: 4)Date of birth:
5)Religion: 6)Social Status:(SC/ST/BC with group/OC)
7)Relaxation of age if any:
8)Whether belongs to physically handicapped:
(Latest Certificate issued by the Medical board(SADAREM)only to be enclosed)
9)If belongs to Ex-Service men, length of service in armed forces
(Certificate to that effect to be enclosed)

10)Details of Education qualifications from Class-IV to X Class 11)Local/Non Local


Year of
Sl.N Class Name of the School studied District
o passing
1 4thClass
2 5thClass
3 6thClass
4 7thClass
5 8thClass
6 9thClass
7 10thClass
11. Marks Obtained in Qualifying Examand Technical Qualifications
Academic& Month & year Marks/Grade
Max. % Marks /
Technical of passing Points
marks/Grade Grade
qualifications obtained
Points points
SSC/10thClass
Intermediate
Technical Qualification:
12. Experience:
AP MCI/APNMC/AP Para Medical Board
Registration Number and valid up to

13. Address of Communication along with Pin code:


Name :
House Number :
Village/Town :
District :
Phone/ Mobile No. : e-mail address:

DECLARATION
I do here by declare that all the above facts are true and correct .I further declare
that, if the above particulars are found incorrect, I shall be liable for termination from service
with immediate effect without assigning any notice

SIGNATUREOFTHECANDIDATE
VERIFICATIONCHECKLIST

ApplicationNo:
Name of the Applicant:
Name of the Post applied:

Copy of marks memo of SSC or equivalent certificate


1 YES NO
Verified.

2. Copy of Intermediate Marks memo Verified. YES NO

3. Copy of marks memos of Technical Qualification YES NO

Copy of Apprentice completion certificate in case of


4. YES NO
Intermediate Vocational Verified.

Copy of APMCI/APNMC/APPM Board registration


5. YES NO
Certificate Verified.

6. Copy of latest Caste Certificate(incase of SC/ST/BC) Verified. YES NO

Copy ofStudyCertificatesfromClass–
7. YES NO
IVtoXwherethecandidatestudiedVerified.

Copy of latest Physically handicapped certificate


8. YES NO
SADAREM (if applicable) Verified

Copy of certificates supporting Ex Service Man


9. YES NO
Quota (if applicable)Verified.

Copy of Certificate of Experience


10 (If Service Persons) duly counter signed by the District YES NO
authority)
11 All the above documents should be attested. YES NO

12 Signature of the application & check list. YES NO

Receiving Clerk. Signature of the Candidate

You might also like