The Christian Medical Association of India
Address to:-
ADMINISTRATIVE MANAGER
Christian Medical Association of India PASSPORT SIZE
Plot 2, A – 3 Local Shopping Centre RECENT
Janakpuri PHOTOGRAPH
New Delhi – 110 058
APPLICATION FOR EMPLOYMENT
Please fill in the form correctly in your own handwriting
1) Post applied for :-Project Manager
2) Full Name :- Pradeep K Panda.
3) Present Address___At:- Plot no:-1028/399 Nayapally, Gadasahi,
Bhubaneswar___751012_________________________________________________________________________________
Email: pradeepbalasore@[Link] Phone / Cell:_09437245404
4) Permanent Address_At:- Bikash Nagar, Angaragadia, Po/Dist:-Balasore-756001, Orissa
5) Date of Birth:-12th April 1982 6) Place of Birth:-Orissa
7) Single/ Married/ Widow/ Widower:-Single 8) Nationality:-Indian
9) (a) No. of Children and ages__________________________________________NA____________________________________
(b) Any other dependents and their ages__________________No___________________________________________________
_____________________________________________________________________________________________________
10) Father’s/ Husband’s/ Guardian’s Name:-Sarat Chandra Panda. (Father)
11) Father’s/ Husband’s/ Guardian’s Profession:- [Link]
12) Religion :-Christian 13) Denomination:-Protestant
14) Height :-5ft6inch 15) Weight:-67 kg
16) General condition of health – Excellent/ Good/ Fair : Excellent
17) Have you any physical handicaps – Sight/ Hearing/ Speech/ Limbs_______NO________________________________________
18) Have you had any major illness in the past year (Yes/No)_____________NO__________________________________________
19) Have you had illness in the past three years where you lost more than 15 days? - Yes/No______NO________________________
(if yes, please give particulars)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Recent Medical certificate be attached
20) Languages know (a) Speak, Read, Writ:-English, Hindi, Oriya
(b) Speak only:-Bengali
21) List your education and professional qualifications:-
Name & Address of Period of Study Degree Diploma Certificate Date of completion
Institution [Link]
From To
2009 2011 MBA/MPSM(HealthCare &
IISWBM, Kolkata Hospital) 2011
K.M. Institute of 2003 2007
Pharmaceutical [Link] 2007
Sciences
1999 2001 10+2 2001
[Link]
1999 10th 1999
Zilla School
Certified copy of degree, diplomas etc. to be enclosed
22) Registration No.:- (Registered with Pharmacy Council of India under section 31(a) & 32(b) bearing certificate number-
19909
23) State Registration Authority:-Pharmacy Council of India,Orissa
24) Previous experience and service record
Name & Address of Post held Period of employment Reason for leaving
Employer
From To
Pharmacy 6th April 12th July 2009
Sparsh Hospital & manager 2007 Higher Study
Critical care [Link].
Sahid
Nagar,Bhubaneswar
25) Present or last salary drawn (basic)________Rs.13,650/-_____________________________________________________________
(a) In scale if any______________________________________________________________________________________
(b) Allowances________________________________________________________________________________________
26) Which position or department did you consider most interesting and why?
Any Health Care management field because I do think I can execute my Knowledge & experience in that field
27) What extra curricular activities did you participate in, if any?:- I am a member of Students& Professionals Fellowship
28) What office or position did you hold in such activities?:- Active Member
29) Where did you spend the greater part of your life upto16 years of age?:-Orissa
30) How long have you lived at the present address:- 4years
31) Do you regularly read any of the following type of magazine?
News:- Times of India, India Today Fiction:- Ahwan(Oriya)
Professional:-CIMS, IDR, Phramacy Choice, IHI Others :-Books related to The Holy Bible
Give particulars ________________________________________________________________________________________
32) What subjects in school or college interested you most? Science related to the same.
_____________________________________________________________________________________________________
33) Have you at present any particular hobbies or recreational interests? Yes/ No
________________________YES_____________________________________________________________________________
34) Reasons for leaving the present job:- I am presently not employed, I have just Completed MBA(Heath Care & Hospital)
35) Please state below what consideration led you to apply for a post in CMAI:-
CMAI’s commitment towards society for its holistic welfare & development.
36) Are you willing to be transferred to any part of India where CMAI offices might be situated?
Yes/ No. If not, give reasons
YES
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
37) Are you involved in any Christian activities or organisations e.g., UESI, YFC, Sunday School, etc.
Yes/ No. If yes, state particulars
YES, I am an active participant of Youth Fellowship of New Creation Chruch.
_____________________________________________________________________________________________________
38) Have you any liabilities or debts – Yes/ No - If yes, give particulars
______________________________NO_______________________________________________________________________
_____________________________________________________________________________________________________
39) Are you at present bonded or under contract to any institution or government?
____________________________________NO_________________________________________________________________
40) If you are called for an interview, would you be able to come at your own expense? Yes/ No___________YES________________
41) How soon could you join if selected?__________________15 days_____________________________________________________
42) Duration of appointment desired:- As CMAI decide.
43) Reference: Please give their full address/ phone /Email address
[Link] James, ICHTHUS HOUSE,Cuttack-1,mob:-0943764737,E-mail:-dr.niranjan_james@[Link]
(a) A professor or Senior Officer to whom you have been responsible within the past 12 months.
Dr. sanghamitra Sen, Co-Ordinator, IISWBM,Kolkata
(b) Your present pastor or spiritual leader
[Link] Kumar Das. Mob:- 09338047307 ;Mail id:- newcreation_bls@[Link]
(c) Someone other than a relation who has know you during the past five years:
Mr. Priyabrata Mohapatra
CEO, Konark Health Care [Link]
Jaydev Vihar
Bhubaneswar
Orissa. Mob no:- 09437014753 ; Mail id:- priyabrat753@[Link]
44) Any further information about yourself that you would like to give in support of your application
I have considerable knowledge in Herbal Medicines & Ayurvedic System of medicines. I am well versed with computer
application & Cif-tech programme. Excellent communication, interpersonal and relationship management skills are my
forte
BASIC SALARY –
DA –
HRA –
CCA –
TRANSPORT ALLOWANCE –
MEDICAL REIMBURSEMENT (ANNUAL) –
HOSPITALIZATION (ANNUAL) –
LEAVE TRAVEL ALLOWANCE –
PF CONTRIBUTION OF EMPLOYER –
CHILDREN EDUCATION ALLOWANCE –
ANY OTHER ALLOWANCES –
(PLEASE MENTION SEPARETLY)
TOTAL MONTHLY PRESENT SALARY –
I HEREBY CERTIFY THAT ALL THE FORGOING INFORMATION IS TRUE
Date :11/2/2011
Place:-Bhubaneswar
Pradeep Kumar panda
Applicant’s Signature
FOR USE IN THE OFFICE ONLY
(Not to be filled the applicant)
1) Application received on _________________________________________________________________________________
2) Application form sent on_________________________________________________________________________________
3) Application form received back on_________________________________________________________________________
4) References called for on_________________________________________________________________________________
5) Reference received on___________________________________________________________________________________
6) Application considered by________________________________________________________________________________
On________________________________________________________________________________
7) Interview on___________________________________________________________________________________________
8) Result of interview______________________________________________________________________________________
9) Joining Date, if any_____________________________________________________________________________________
10) Any other remarks______________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
