Online Application- National Health Mission, Assam

ONLINE APPLICATION UNDER NHM , ASSAM

The fields, which are marked with asterisk (*) are mandatory fields.

*Applied for

*Name of Applicant

*Date of Birth (As per Matriculation Cerftificate)

*Gender

*Caste

*Mobile No

*E-Mail ID

*Father's Name

*Are you a Person with Disability (PWD) ?

Correspondence Address

*C/O:

*House No.:

*Vill/Town:

*Post Office:

*Police Station:

*District:

Enter District Name

*Enter District Name:

*PIN:

*State

Permanent Address

Same As Correspondence Address

*C/O:

*House No.:

*Vill/Town:

*Post Office:

*Police Station:

*District:

*Enter District Name:

*PIN:

*State

*Essential Qualification (As per advertisement)

Qualification Name of Course Course Duration in year Course start date Course end date Institute Name University Name Mode of Course Subjects Year of passing % of Marks obtained Division/ Class /Grade

Qualification Details

Exam Passed Name of Degree Subject Stream Institution Name University Name Course Duration in year Year of passing % of Marks Division/ Class /Grade Full Time/ Correspondence/ Distance

* 10

10+2

Degree

PG

Professional Qualification

Other Qualification

Registration Number

Registration Under

Registration No.

Experience Details

Name of Organization Designation Nature of duty From Date To Date Year of Service (YY/MM)

*Total Experience in months

Computer Proficiency

Are you proficient in Office Application Software?

Remarks if any(Max 255 words allowed)

Declaration

I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found untrue or incorrect at any stage of my not satisfying any of the eligibility criteria stipulated, my candidature is liable to be cancelled.

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