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Covid 19 National [Iealth Mission

District Integrated Health & Family Welfare Societyrlalgaon

APPLICATION FORM

(All /ieldsinlheformsare mandatory tobeJilled.An incomplete form submittedwill betreated as rejected.)

,\rldrcss / Contnct Dclrils: Nnrne of thc District antl Pin code is conr

Atlttress (Present):

Dislrictr Pin:('onlilcl No:I.l-rnrtil Itl lor Corresllondence:

\ cit d c nr i c / P lofcssi on a I E cl u cirtio n Su nr nr ir from most recent)liinll \ carljronr

( l\l i\ l/\'\')'l'o

( i\ti\ I/\'\') I 0talNIurli\&Obtirinerl Nlrrrlis

ll ct:potr: ibilitict(,llitr. -10 trtrtl .llrt-r, 50 Il ortls)

Corrttcil Ragistrolion Certi/icute:ltlnchei (if'Applicubla) - Yes / No

Got'1. Ll'ork / E.rpct'icttce Suntntort,: (Sturling front current / tl1osl recettl)

Sr.

,\tLOrgurtizullon Designotion

'l oritl lixlteriettca (Itt l'ettrs & lfottllts): ll c I ev t tt I ll.r p e t' i tt r t t t I o I I t c 1 t o : t it p p I i t I 1 I tt ) L Lt r s,l

llonths):

Declaratian:I hereby declare that allstatements made in the application are true, complete and correctto the be st of rny knowle dge and beltef . I

Lttclerstand that in lhe event of any information being found untrue/false/incorrect or I do uot sattsfy the eligibiltty cnltena nty

canclidatLtro vtill be cancelled. v,tithout assigri/lg any reason thereof . I have read the content of the advertisement and agree ta abtde

by tlte rules, regLtlations and procedures for appointnent to the post applied for

Signatu re

Discl:rirrr u':

Name of Post :

Name of Candidate :

Datc of Ilirth (DD/N'lN{/\'YYY): Illoocl Crou;r: (lcndcr:

\[lritrlStl tus:

t)risting Nllr\l(\'cs/Nn)

Nutiorrnlitr': Rcligion: ('irtegorr:

Degree / Diploma t niversit'r / InstitutcSpecialization /

Su bj ects