ORM. General Information of Candidate for the Post of Asst. Malaria Inspector, Post Code-21/14, ‘Asst. Public Health Inspector, Post Code-22/14, Vaccinator, Post Code-29/14 and Asstt. Sanitary Inspector, Post Code-93/14 and Checklist on uploading the documents. (To be uploaded by candidate) 'SNo. | Post coa Admit Card No, | Roll Nun | applied for PP PI Photograph 1. If you are a valid candidate for more than one post out of post code 21/14, 22/14, 29/14, {93/14 please give your order of preference for selection to posts: Preference Post code 1) First Preference i) Second Preference i) Thies Preference | ) Fourth Preference [| Note:- Order of preference given cannot be changed subsequently, 2. Nome of Candidate Father's Name Name of Husband (in married case) 5. Permanent Address 5.2 Correspondence Address 5.3 Mobile No, 6 Information on Birth (i) Date of sireoo/Mnaryery) a A (i) Whether uploaded copy of relevant documents In support of date of birth [ss ] No (Tick inthe relevant box) (ii) Ageason 27.02.2014 Signature of candidate Name Roll No.7.Are you seeking age relaxation = =] 7.1 If yes, then specify the age relaxation category (Tick Vin the relevant box) PHIOHNH/H) OGM | Gowt | Serie — 72 Whether uploaded copy of relevant certificate as per 7.1 £8, Detals of Category and Sub-category ‘Atm ease of $C/St/08C |) Number and date of ise of Sc/ST/OBC certificate 1) Designation ofisuing authority: ii) Tehsil/District of tsuing authority: 1 Sate of issuing authority: 3. Incase of PHIOH/VH/HH) i) Number and date of issue of Disability certificate: i) Designation of fsuing authority: 1 Hospital/Medical Institution of issuing authority iv) Tehsi/Distrct of issuing authority vy) State of isuing authority: i Sage of Disability indicated by issuing authority’ Cc Inease of EXSM i) Date of joining of Defence service: Ii) Date of dischargefretirement from Defence service i) Total length of service rendered in Defence: {iy} Name of unitfoffie atthe time of Discharge: v) Address ofthe unit/office at the time of discharge: vv Whether you have worked/working on any civil post Yes No vi) Incase of yes, specify deta 8D. Incase of Departmental candidate }) Name of current Government Govt, Offce/ Organisation where employes 1) Address ofthe current Govt, office / Organization where employed: ii) Whether the Govt office organization ro] an iv) lf State, Name ofthe State: }_ lf Central, name of the Ministry: Signature of candidate Name. Roll No.vi Whether the office/orgnasation is Autonomous ah ves No vil) Date of substantive appointment on regular Basis{Attach copy of appointment order): vil) Designation of the current post: 9. Details of Educational Qualification: 1) Matriculation 3} Date of decaration of final result b) Name ofthe Board / Institution } Overall age of marks 2} Whether uploaded copy of Board Certificate: Yes je) (Tieky in relevant box) 20. Information regarding Diploma Certificate of Sanitary Inspector: (Date of declaration of final result of Diploma: (i) Date of issue of Certificate about qualifying Diploma (ii) Name of the University/institution (iv) Whether the institution is Govt/Prvate () Incase of Private, attach documentary proof of recognition ofthe diploma course 35 well as University/nsttution itself Vi) Whether uploaded copy of Diploma Certieate [~ ] of Sanitary Inspector/health inspector: 11. Information regarding Diploma Cetiicate of health inspector: (0) Date of deciaration of final result of Diplo: (i) Date of isue of Certificate about qualifying Diploma (li) same of the University/insttution (iv) Whether the institutions Govt /Private (o) Incase of Private, attach documentary proof of recognition of the diploma course aswellas Universty/insttution itself vil) Whether uploaded copy of Diploma Certificate [== 7a of Sanitary Inspector/health inspector: DECLARATION | That the information provided above are true to the best of my knowledge and belie {i} That fulfil al the eligibility conditions a presrited inthe Advertisement for which | am Claiming my candidature. ii) That also understand that in ease any information is found to be wrone/misleading or any documents uploaded by me found to be orged or Incorrect or notin coherence withthe prescribed requirement, then my candidature i fable to be rejected, besides warranting legal/riminal action f any. Signature of the CandidateThe candidate should not write below this line for use of the ossse) Name ofthe Canalaate category Roll Number Shortstes category PostCode The candidate has been found eligible hasbeen found/nc lle on the basis ofthe document Eligible ineligible Reason for ineligibility Remarks if any Ceried that candidature has been found to have fuflled/not fufled the eb criteria on the bass of doeument provided by the candidate Check by Name & Signature of Dealing Hand Remarks of Supdt, if any, Name Signature of Supa. Remarks of By Secretary, if any "Name & signature of Oy Secretary Deoing Han Rea nk Supa Green nk Dy Secretory: Bue nk