Online Application Form

for Certificate in Community Health (CCH-NHM-MP) under National Health Mission, MP,
Department of Public Health and Family Welfare, Govt. of Madhya Pradesh

1. Personal Details: व्यक्तिगत विवरण:

Application No.: आवेदन संख्या : 17080

Candidate's Name: Pankaj Kumar Carpenter Father's/ Husband's Name: SUNIL KUMAR Photograph:
आवेदक का नाम पिता / पति का नाम

Gender: लिंग: MALE Date of Birth (DD/MM/YY): जन्मतिथि 05-Jun-1998

Mobile Number: मोबाइल नंबर : 8349790102 Alternate Number: दूरभाष संख्या : 8349790102

Email ID: ईमेल आईडी : pankajcarpenter68@gmail.com Category: (वर्ग): OBC

Marital Status (वैवाहिक स्थिति) * Single WhatsApp Number 8349790102

Domicile Details: अधिवास विवरण: Agar Malwa, Madhya Pradesh Person with Disability (PwD) : NO:

Examination Center/ Cities Preference: 1. Ujjain 2. Indore 3. Bhopal 4. Jabalpur 5. Gwalior 6. Rewa

Program Study Centre Preference: 1. Government Nursing College, Ujjain 2. Choithram College of Nursing, Indore 3. J.P. Hospital Bhopal 4. Kushabhau Thakre Colleg
e of Nursing, Bhopal 5. Rani Durgavati Government Nursing College, Jabalpur 6. RHFWTC, Jabalpur 7. RHFWTC, Gwalior 8. G.N.M.
T.C, Seoni

Any criminal case under consideration in the court or has been punished ever by the court: No

2. Address: पता
Correspondence/ Current Address with Pin Code: Permanent Address with Pin Code:

GRAM SUDWAS TAHSIL BARODE DISTRICT AGAR MALWA GRAM SUDWAS TAHSIL BARODE DISTRICT AGAR MALWA
465550 465550

3. Educational Qualification Details: शैक्षिक योग्यता विवरण:

Course Specialization/ Subject Name of University/ Institute Mode Of Course Marks% Course Duration

10th ALL MPBSE BHOPAL, Madhya Pradesh Full Time 56 ( Percentage: 01-Jul-12 to 31-Mar-13
56)

12th Science BIO Group MPSOS, Madhya Pradesh Other 54.20 ( Percentage: 01-Jul-16 to 30-Jun-17
54.20)

GNM GNM NURSING COUNCIL Full Time 71.25 ( Percentage: 01-Jul-17 to 31-Jan-20
MADHYAPRADESH, Madhya Pradesh 71.25)

Have you taken admission for the CCH Training Course by NHM, MP previously? क्या आपने इससे पहले नेशनल हेल्थ मिशन, मध्य प्रदेश (एनएचएम, एमपी) द्वारा सीसीएच प्रशिक्षण पाठ्यक्रम में प्रवेश
प्रवेश प्राप्त कियाहै? Please Note: जिन उम्मीदवारों द्वारा पूर्व में इस प्रषिक्षण हेतु प्रवेश प्राप्त किया गया है उन्हें पुनः प्रवेश की पात्रता नहीं है. : No

Declaration by Candidate:

1. I hereby declare that the above information given by me is complete and true. In case provided information found incorrect, my application can be canceled.
2. I do hereby declare that no legal and/or criminal case is pending against me before any court/investigating agencies. I further declare that I have never been found guilty/convicted of any legal offense
and/or crime by any court of law in the past. In case the information furnished by me in my online application form found to be false, NHM, MP has the liberty to cancel my application.
3. After successful completion of training, I will be posted as Community Health Officer at rural sub-health centers and in the event of not being served there, I will be separated from service. I agree with this.
4. I have studied the Rule Book and agree to abide by the provisions/rules mentioned therein.

1. मै घोषणा करता/करती हूँ कि मेरे द्वारा दी गई उपरोक्त जानकारी पूर्ण एवं सत्य है। जानकारी असत्य होने की दषा में मेरा आवेदन पत्र निरस्त किया जा सके गा।
2. मै प्रमाणित करता/करती हूँ कि मुझे किसी अपराध में किसी न्यायालय द्वारा न तो दोषी पाया गया है और न ही मेरे विरूद्व इस प्रकार का कोई भी प्रकरण किसी भी न्यायालय में विचाराधीन है। जानकारी असत्य होने की दषा में मेरा आवेदन
पत्र निरस्त किया जा सके गा।
3. सफलतापूर्वक प्रशिक्षण पूर्ण करने के उपरांत, कम्युनिटी हैल्थ ऑफिसर के रूप में मेरी पदस्थापना ग्रामीण उपस्वास्थ्य के न्द्रों पर की जायेगी एवं वहां रह कर सेवायें न देने की स्थिति में मुझे सेवा से पृथक कर दिया जायेगा। मैं इससे सहमत हूँ।
4. मैने नियम पुस्तिका अध्ययन कर लिया है एवं उसमें वर्णित प्रावधानों/नियमों को मानने के लिये सहमत हूँ।

Date: 05-Mar-2022
10/26/23, 7:09 PM about:blank

Photo
Personal Details Signature
Applicant's PANKAJ KUMAR CARPENTER / पंकज
Profile Id 1062231283412
Name कु मार कारपेंटर
SUNIL
Father's Name Mother's Name SANGEETA BAI
KUMAR
Date of Birth (dd/mm/yyyy)
(As per class 10th mark sheet or birth 05/06/1998 Gender पुरूष (M)
certificate)
Domicile State Madhya Pradesh Category अन्य पिछड़ा वर्ग (क्रीमलेयर को छोड़कर) (OBC)

Handicapped Details
Are you a handicapped (Minimum 40 percent) नहीं(No) If yes, type of disability
If the applicant is locomotor disabled, its type -
Marital Status
Are you married? नहीं(No) Spouse Name
Date of marriage if the applicant is married (dd/mm/yyyy) -- जीवित बच्चो की संख्या
Date of Birth of Last Child (dd/mm/yyyy) -- क्या अंतिम बच्चे जुड़वा हैं? नहीं(No)

Contact Details
Present Address
Address GRAM SUDWAS TAHSIL BARODE DISTRICT AGAR MALWA 465550
State MADHYA PRADESH District AGAR MALWA Pin Code 465550
Permanent Address
Address GRAM SUDWAS TAHSIL BARODE DISTRICT AGAR MALWA 465550
State MADHYA PRADESH District AGAR MALWA Pin Code 465550
Mobile No XXXXXX0102 Email XXXXXXXXXXXXXXXXXX@gmail.com
Qualification Details
Passed
Course Pass University / Board Course Obtained Total Percent
Qualification Exam Subject Roll No.
Type Year Name System Marks/Points Marks/Points %
Name
10th (High General
Full
HSC School - All 2013 MPBSE BHOPAL 134522533 MARKS 336 600 56.00
Time
Certificate) Subjects
11th / 12th
(Higher
Science- Full MPSOS madhya
HSSC Secondary 2017 470017300106 MARKS 217 500 54.20
Biology Time pradesh
School
Certificate)
GNM -
NURSING
General
Full COUNCIL
Diploma Nursing GNM 2021 G35J2153510123 MARKS 285 400 71.25
Time MADHYAPRADESH
and
madhya pradesh
Midwifery
Download Caste Certificate Download Domicile Certificate

about:blank 1/1
10/26/23, 6:57 PM about:blank

Photo
Personal Details Signature
Applicant's PANKAJ KUMAR CARPENTER / पंकज
Profile Id 1062231283412
Name कु मार कारपेंटर
SUNIL
Father's Name Mother's Name SANGEETA BAI
KUMAR
Date of Birth (dd/mm/yyyy)
(As per class 10th mark sheet or birth 05/06/1998 Gender पुरूष (M)
certificate)
Domicile State Madhya Pradesh Category अन्य पिछड़ा वर्ग (क्रीमलेयर को छोड़कर) (OBC)

Handicapped Details
Are you a handicapped (Minimum 40 percent) नहीं(No) If yes, type of disability
If the applicant is locomotor disabled, its type -
Marital Status
Are you married? नहीं(No) Spouse Name
Date of marriage if the applicant is married (dd/mm/yyyy) -- जीवित बच्चो की संख्या
Date of Birth of Last Child (dd/mm/yyyy) -- क्या अंतिम बच्चे जुड़वा हैं? नहीं(No)

Contact Details
Present Address
Address GRAM SUDWAS TAHSIL BARODE DISTRICT AGAR MALWA 465550
State MADHYA PRADESH District AGAR MALWA Pin Code 465550
Permanent Address
Address GRAM SUDWAS TAHSIL BARODE DISTRICT AGAR MALWA 465550
State MADHYA PRADESH District AGAR MALWA Pin Code 465550
Mobile No XXXXXX0102 Email XXXXXXXXXXXXXXXXXX@gmail.com
Qualification Details
Passed
Course Pass University / Board Course Obtained Total Percent
Qualification Exam Subject Roll No.
Type Year Name System Marks/Points Marks/Points %
Name
10th (High General
Full
HSC School - All 2013 MPBSE BHOPAL 134522533 MARKS 336 600 56.00
Time
Certificate) Subjects
11th / 12th
(Higher
Science- Full MPSOS madhya
HSSC Secondary 2017 470017300106 MARKS 217 500 54.20
Biology Time pradesh
School
Certificate)
GNM -
NURSING
General
Full COUNCIL
Diploma Nursing GNM 2021 G35J2153510123 MARKS 285 400 71.25
Time MADHYAPRADESH
and
madhya pradesh
Midwifery
Download Caste Certificate Download Domicile Certificate

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