Attested Passport size Photograph A P P L I C A T I O N F O R M F O R M E D I C I N E S C O N SU L T A N T S U N D E R T H E J & K ST A T E H E A L T H P L A N Position Applied for: 1 . F i r s t N a m e : L a s t N a m e : 2. D a t e o f B i r t h : 3. District of Domicile 4. Sex 5. Present Contact Address: 6. Permanent Telephone No. (STD code) 7. Present Telephone No. (STD code) 8. E m a i l A d d r e s s 9. Mobile No. 10 Languages Spoken /Written 1 1 . C o m p ut e r L i t e r a c y : Mention all software(s) known/used 11. A (For Data Assistant Only) indicate speed in words per minute English Hindi Other Languages Typing (on computer) Shorthand 1 2 . E d uc a t i o n : High School onwards, please list all your qualifications Degree Institute/Board & location Year Percentage/Rank Full/Part time 1 3 . D e t a i l s o f e x p e r i e n c e ( us e s e p a r a t e s h e e t s i f r e q ui r e d ) Starting with your present employment, list in reverse order all the employment you have had with job responsibilities 1 4 . R e f e r e n c e s : List two persons, not related to you, who are familiar with your experience and qualification Full Name, Address and Telephone Nos(s) Designation, Organization & professional relationship A n y o t h e r r e l e v a n t i n f o r m a t i o n I certify that all statements made by me to the above questions are true, complete and correct to the best of my knowledge. Place: Signature Date: N a m e ( i n b l o c k l e t t e r s ) N.B. You will be required to supply documentary evidence, which supports the statements you have made above. Do not, however, send any documentary evidence until you have been asked to do so
