DIST.
MEDICAL & HEALTH OFFICE, NIRMAL
NOTIFICATION NO. 02/2024, Date: 29.02.2024.
Recruitment of District Programme Officer / Psychologist / Refrigerator Mechanic /
Staff Nurse / ANM / DEO cum Accountant On Contract / Out Sourcing basis under NHM.
APPLICATION FORM FOR THE POST OF ………………………………
(Office use only)
Appl. No.
1. Name of the Candidate
2.a Name of the Father
Paste Photograph
2.b Name of the Mother here and sign
Name of the Husband across it
2.c
(If married)
3 Date of Birth
BC BC BC BC BC EWS
OC SC ST
4 Social Status (Please tick) –A –B –C –D –E
Whether physically YES / NO
5
handicapped (Please tick)
If yes please mention HH / OH / VH
5 (a)
category (Please tick)
6 Whether Ex-Servicemen YES / NO
7 Whether belongs to EWSs YES / NO
7. Details of School Education:
CLASS YEAR OF PASSING DISTRICT IN WHICH STUDIED
I
II
III
IV
V
VI
VII
8. District to which candidate belongs as per presidential order:
9. Educational Qualifications:
YEAR OF
QUALIFICATION NAME OF THE SCHOOL/ BOARD
PASSING
Contd ……. 2.
// 2 //
10. Marks obtained in the Qualifying / Technical examination:
Qualifying
Total Marks Marks Obtained % of Marks Obtained
Examination
11. ADDRESS PARTICULARS:
Name :
Father/ Husband Name :
House No. :
Street :
Village / Town :
District :
Pin :
Cell No. :
DECLARATION
I, Kum./ Smt. …………………………………………… , D/o / W/o ………………………… ……..
certify that above particulars furnished by me are correct to the best of my knowledge. I also
agree that in the event of any of the particulars furnished in my application being found to be
incorrect or false at a later date my candidature will be cancelled summarily.
Name and Signature
Of the candidate
HOW TO APPLY:
a. Filled in application forms shall be submitted in person or through registered post to
the respective District Medical & Health Officers [ O/o District Medical & Health Officer,
F-25, Integrated District Offices Complex (IDOC), Nirmal ] to the district to which the
candidate is applying. Applications which are received after due dates will be
summarily rejected. District Selection Committee is not responsible for postal delays.
b. Self attested copies of the following certificates should be enclosed along with the
application form:
1 S.S.C / Date of Birth Certificate issued by the competent Authority of the Government
for proof of age.
Intermediate or 10 + 2 examination.
3 Qualifying Examination Pass Certificate.
4 Marks Memos of all the years (qualifying examination)
5 Registration Certificates of respective Councils / Boards.
6 Latest Community Certificate / EWS Certificate / Ex Servicemen / NCC / Physically
Handicapped certificate, whichever is applicable, issued by the competent authority.
7 Study certificate for the years from 1th class to 7th class and in case of Private Study,
residence certificate from the Tahasildar / MRO concerned to be Submitted.
8 PH certificate in respect of candidates claiming reservation under PH Quota.
9 Relevant certificates in respect of candidates claiming Ex-service Men Quota.
10 Registration Certificate from the concerned Medical Council / Nursing Council / Para
Medical Board / Other relevant authority.
11 (1) Photograph duly pasted on the application form.
DIST. MEDICAL & HEALTH OFFICE, NIRMAL
Notification No 02/2024, Dt.29.02.2024
Recruitment of District Programme Officer / Psychologist / Refrigerator Mechanic / Staff Nurse
/ ANM /DEO cum Accountant On Contract / Our Sourcing basis under NHM.
ACKNOWLEDGEMENT TO CANDIDATE
Application for the post of …………..………………………………….. is received from
Name of the Candidate :
Fathers/ Husband Name :
Date of Acknowledgement :
Signature :
Seal :
