Application Cum CONCENT FORM For Administrative Posts-Consultant/Asst.Dir./Deputy Dir./Joint Dir.

Application ID:
Name: Father's /Husband Name:
Category Date Of Birth:   (dd/MM/yyyy)
Gender:    
Mobile No: Email ID:
Current Address:
Division: District:
Block: Address:
Permanent Address:
Employment Details:
PSC Year & Merit No: Date of First Joining(dd/MM/yyyy):  
Currently working as: Place of Posting:
Date of Posting at present posting place:   Current basic Salary (as per 6th pay) Details / Month:
Treasury ID:
Education Qualification(regular course):
S.No. Qualification Details Institute/University Passing Year Result In%  Upload Document
1 High School   (only jpg ,pdf)
2 Higher Secondary   (only jpg ,pdf)
3 MBBS   (only jpg ,pdf)
4 M.D./M.S. Diploma   (only jpg ,pdf)
5 Any Other health related[Regular Courses Only]   (only jpg ,pdf)
Preferred Field Of Work    
List Of Rewards/Recognitions:(in last 05 years)    
1. 2.
3. 4.
Certification By CMHO
This is certify that the details, Submitted above by Mr./Ms ........................................................................
S/o ,W/O .............................................................................Posted as........................................................
At ........................................................................................Since..............................................................
        His current salary is ..............................(Basic+Grade Pay+allownces =Total). no complaint/ inquiry
/Legal Proceeding is pending against him/her.His/Her details of CR Grading/Leaves/Trainings in tha last
05 years is as below:
S.No. Year CR Grade Leaves/Unauthorized absence Training
1 2016-17
2 2015-16
3 2014-15
4 2013-14
5 2012-13
                                  
Seal & Signature of CM&HO /BMO
Date:                                  
District:                                  
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