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Application Form

Pradeep Kumar Mahapatro has applied for the position of Executive Grievance-SHAS in Odisha. He provides his personal details including his father's name, date of birth, contact information, gender, age, category, and address. Pradeep lists his educational qualifications including a degree from Berhampur University in 2001. His experience details include working as an Assistant Professor from 2010 to 2018 at Centurion University. Pradeep declares that the information provided is true and he is willing to provide original documents if invited for an interview.

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82 views2 pages

Application Form

Pradeep Kumar Mahapatro has applied for the position of Executive Grievance-SHAS in Odisha. He provides his personal details including his father's name, date of birth, contact information, gender, age, category, and address. Pradeep lists his educational qualifications including a degree from Berhampur University in 2001. His experience details include working as an Assistant Professor from 2010 to 2018 at Centurion University. Pradeep declares that the information provided is true and he is willing to provide original documents if invited for an interview.

Uploaded by

pradeepkumar.mahapatro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

APPLICATION FORM

Advertisement No. : 02-2023


Application no. : NRHM_EGS_72891
Applied Date : 24/06/2023
Name of the Post : Executive Grievance-SHAS
Applied for State/District : Odisha
PERSONAL DETAILS :
: PRADEEP KUMAR
1. Applicant Name
MAHAPATRO
2. Father's Name : RAMA CHANDRA MAHAPATRO
3. Date Of Birth : 14/07/1981
4. Mobile No. : 8249875112 5. Email Address : [email protected]
6. Gender : Male 7. Age as on : 41 Years 5 Months 17 Days
8. Category : SEBC 9. Physically Challenged : No
10. District of Domicile : Gajapati
: House No-302, Ward No- : House No-302, Ward No-
07,Radhagovind Nagar Line-II, 07,Radhagovind Nagar Line-II,
11. Present Contact Address 12. Permanent Contact Address
Parlakhemundi, Gajapati,Odisha, Parlakhemundi, Gajapati,Odisha,
761200 761200

13. QUALIFICATION DETAILS (STARTING FROM HIGHER QUALIFICATION) :

Name of
Name of the Year Of Month Of Duration Of
Board/Universit Full Mark Marks Secured Percentage Full/Part Time
Examination Passing Passing Course
y
Berhampur
Degree 2001 July 1800 994 55.22 3 years Full Time
University

14. EXPERIENCE DETAILS (STARTING FROM PRESENT / LAST EMPLOYMENT) :

Name of the Employer Post Held From Date To Date Total Year Total Month
Centurion University Asst.Prof 01/01/2010 03/01/2018 8 0

15. PAR DETAILS OF LAST THREE CONTRACT PERIOD (FOR OSH&FW EMPLOYEE ONLY) :

Designation From Date To Date Remarks in PAR

16. Experience details under OSH&FW Society (Only for employees working under OSH&FW Society):

Name of the Post and Place


From Date To Date Total Year Total Month
of Posting

DECLARATION :
I do hereby declare that the information furnished above are true to the best of my knowledge and belief and that, if at any stage, it is found that
any of the above material information is false / incorrect or is suppressed by me, my candidature / appointment under Odisha State Health &
Family Welfare Society (OSH&FWS), Odisha is liable to be rejected/terminated.I also declare that I have never been disengaged from service
under the OSH&FWS,Odisha on administrative ground such as disobedience/poor performances/misbehavior/criminal activity etc.

Further, I undertake that I shall produce all original certificates/documents in support of the above information at the time of
interview/certificate verification.

Date :
Place :
Full Signature of the Applicant

Enclosure (Self attested copies):-


1. 10th Mark Sheet and Certificate
2. +2 Mark Sheet and Certificate
3. Diploma Mark Sheet and Certificate (if applicable)
4. Degree Mark Sheet and Certificate
5. P.G. Degree Mark Sheet and Certificate
6. No Objection Certificate from candidates working under Health Dept.
7. One Recent Passport size colour photograph
8. Experience Certificate
9. Any Identity Proof
10. PGDCA/DCA/any other Certificate (if applicable)
11. Registration Certificate (if applicable)

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