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Application for the post 

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Mission Director
National Rural Health Mission,
Mantralaya Parisar, Raipur (C.G.)  

Post:-         Label
1. Applicant's Name:-  
2. Father/Husband Name:-   
3. (a)Date Of Birth:-      
4. Categary (General/ST/SC/OBC):-
5. Gender :-
6. Identification Marks:- 1)
7. Do you a have Domicile certificate of Chhattisgarh State:-
(क्या आपके पास छत्तीसगढ का मूल निवास प्रमाण पत्र है)
8. Domicile District :-
(मूल निवासी जिला)
9. Employment Registration  (रोज़गार पंजीयन)
1)Registration No
(जीवित पंजीयन क्रमांक):
2)Registration Date
(पंजीयन दिनांक):
3)Renewal(Year & Month )
नवीनीकरण(वर्ष और महिना):
4)Employment Exchange Name & Place
(रोज़गार कार्यालय का नाम और जगह ):
10. Are you from Handicapped Category:-
(क्या आप विक्लांग अभ्यर्थी है)
विकलांगता का प्रकार:
विकलांगता का प्रतिशत: 

11. Are you from Ex-Servicemen Category:-
(क्या आप भूत पूर्व सैनिक अभ्यर्थी है)
12. Permanent Address:-
   District :-    State :- 
Mobile/Tel No.:-     
E-Mail ID :-     
13. Residential Address :-
  District :-    State :- 
  Pin :- 
Mobile/Tel No.:-     
14. Essential Qualifications :-
Name of Exam Board Year of Passing Marks Obtained/Total Percentage Class
15. Academic Qualifications :-
Name of Exam Board Year of Passing Marks Obtained/Total Percentage Class
16. Experience Previous Employment(Please State in chronological order(Older Experience than Newer Experince)
From TO Organisation Name Designation Duration(In Month) Duties
17. Total Experience
18. Are you present employee in NRHM :-
(क्या आप एन. आर. एच. एम. के पद पर पदस्थ हैं)
Designation :-
Place of Posting :-
Date of Posting :-  
19. Spouse Details (Working in Govt. Dept./Govt. Bodies) :-
(पति/पत्नी की जानकारी शासकीय विभाग/ शासकीय संस्था)
Name of spouse :-
(पति/पत्नी का नाम)
Name of department :-
(विभाग का नाम)
Place of posting :-
(पद्स्थापना का स्थान)
Block :- 
                                                                                                                                               I hereby declare that the information given in this application form is true and complete.I understand that if it is found at any time before or after selection that any information given by me is untrue or wrong, my candidature for the above post shall be deemed to be cancelled.

Date:-   Signature
Passport Size Photo

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