Online Registration and Application Form

Six-Month Bridge Program (Certificate) in Community Health Under State Health Society,
National Health Mission, Uttar Pradesh

Application No.: SAMSUPNHM0013571

Post Applied for: Community Health Officers
Candidate's Name: Ms. Kalpana
Father's/ Husband's Name: Mr.Munna Lal
Gender: FEMALE
Date of Birth (DD/MM/YY): 15-Jun-1995
Mobile Number: 8445411193
Alternate Number: 7599508577
Email ID: 1506kalpi@gmail.com
Are you fall in the category of differently abled? NO
Category: SC
Domicile State: Uttar Pradesh
Domicile District: Etawah
I- July 2019 Session: Jhansi
Preference:
II- January 2020 Session: Varanasi

2. Address:

Correspondence/ Current Address with Pin Code: Permanent Address with Pin Code:
Jaswant nagar 206245 330018,katra Khoob Chandra, jaswant nagar Etawah 206245

3. Educational Qualification Details:

Essential Qualification*

Name of the Degree/ Passing Marks (in

Name of University/ Institute Mode Of Course
Diploma Year %)
General Nursing and Pushpanjali School of nursing agra. UP state
Full Time JUN-2017 67.50
Midwifery (GNM) medical faculty Lucknow

Other Qualifications

Name of the Degree/ Specialization & Name of University/ Passing Marks (in
Mode Of Course
Diploma Principal Subjects Institute Year %)
Hindi ,English , math,
H. V. Inter College
10th Chemistry, Full Time JUN-2011 40
Etawah
phsics,drawing
Hindi,English,history,
H. V. Inter College
12th civics, sociology,sport Full Time JUN-2013 55
Etawah
and physical education

4. Work Experience:

Key Ares of Experience &

Name of Organisation
1 year experience Yashwant
hospital and trauma center,
new Agra
Designation / Title
I CU Staff nurse
Experience Duration
Job Responsibilities
I am an excellent ICU member
and attendant. I have a very
good eye with my patients. I 06-Jun-17 to 14-Jun-18
have great skills in both
speaking and writing.

Declaration by Candidate: I hereby declare that the information furnished above is true to the best of my knowledge
and any misrepresentation, falsification or omission of information used to secure employment shall be grounds for
rejection of this application and I would liable for legal action, also immediate discharge if I am employed by NHM, UP
regardless of the time elapsed before discovery.

Date: 13-May-2019