Attested Annexure-B Passport size APPLICATION FORM FOR CONTRACTUAL APPOINTMENT UNDER NRHM Photograph STATE HEALTH SOCIETY 1 Post Applied for: _____________________________ 2 Adv. Notice No: _______________________________ 3 Name of candidate: __________________________________ 4 Parentage ____________________________________ 5 6 7 8 9 Date of Birth: PermanentPresent Contact Address: E mail Address Permanent Telephone No. (STD code) Languages Spoken /Written ____________________________ ______________________________ 10. Details of Technical Qualification:- Examination Passed Examining Body/Board/University Year of Passing Marks Obtained Total Marks %age 11. Date of declaration of result of technical Qualification_________________________ 12 Experience if any____________________________ Duration __________________ Years______________ months 13 Documents a) ____________________ b)___________________ c) __________________ d)_______________________ 14 I do hereby declare that i. The Statement in this application is true to the best of my acknowledge and belief ii. I have never been debarred from appearing at any examination/Interview. iii. I have never been arrested /prosecuted or involved in any criminal case registered by the police or convicted by a criminal court. iv. I undersigned that any willful concealment of the facts shall result in the cancellation of my candidature and may also debar me from applying for future selection. I shall accept the selection made by the selection committee which will be binding on me Signature of Applicant Note: You will be required to supply documentary evidence, which supports the statements you have made above before the interview.
