(A Joint Venture of Govt. of India &Govt. of UP. ¼Hkkjr ljdkj ,oa ... Mobile No. +91. Affix recent passport size co
(A Joint Venture of Govt. of India &Govt. of UP. ¼Hkkjr ljdkj ,oa mRrj izns’k ljdkj dk ,d l;aqDr miØe½ (A MINI RATNA SCHEDULE “A”COMPNAY)
Advt. No. ………..
APPLICATION FORMAT (Use Block Letters Only) (Please fill up this form with utmost care)
Affix recent passport size color photograph here
Post Applied for : ________________ A.
PERSONAL DETAILS: 1. Name (as appears in SSC certificate)
Please put a space between your first name, middle name (if any) and last name. 2. Father’s Name 3. Date of Birth
DD
MM
4. Age as on closing date
YY
Month
YYYY Days
5. Sex (write M or F) 6. State of Domicile
B.
CORRESPONDENCE ADDRESS
City/Town
Telephone Number: Mobile No.
State
STD Code +91
Pin Code
Tel. No.
Tel. No.
C.
PERMANENT ADDRESS
City/Town
State
Telephone Number:
Pin Code
STD Code
Mobile No.
Tel. No.
+91
Email Id
D. ACADEMIC /PROFESSIONAL QUALIFICATION (Start from Matriculation/Higher Secondary) Exam Passed
Institution/ University/ Board
Subject of Study
Duration of Study
Month& Year of Passing (MM?YYYY)
Aggregate % of Marks/ CGPA(*)
Remarks
(*if it is Cumulative Grade Point Average (CGPA), please convert it to % of Marks) E.
REGISTRATION NO (Under MCI ACT-1956)/Nursing Council:
F.
Category
(GEN/SC/ST/OBC/EX-SM)
Are you physically handicapped? (Yes/No) If yes please mention the details as follows: VH Type of handicap (please put (√) in appropriate box) Extent of disability as specified in the disability certificate
HH VHVH
OH
Do you belong to Minority? (Yes/No) G.
Religion
H.
Details of Experience (if any)
Name of Organisation
Designation
Scale of Pay
Duration
Regular/Contract/ daily wage
Nature of Duties
From To (MM/YYYY) (MM/YYYY)
Post Qualification Experience: Years
Months
Total Gross Emoluments
Declaration: I affirm that the information given in this application is true and correct to the best of my knowledge and belief. I further undertake that if at any stage it is discovered that an attempt has been made by me, willfully to conceal or misrepresent the facts, my candidature /appointment shall be summarily rejected or terminated without any notice.
