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Application Form

The document is an application form for the position of State Cold Chain Manager in Odisha, submitted by Sushanta Kumar Jena on 10/10/2024. It includes personal details, educational qualifications, and a declaration of the accuracy of the provided information. The applicant has attached various supporting documents, including mark sheets and certificates, for verification.

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sushantakumarj17
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43 views2 pages

Application Form

The document is an application form for the position of State Cold Chain Manager in Odisha, submitted by Sushanta Kumar Jena on 10/10/2024. It includes personal details, educational qualifications, and a declaration of the accuracy of the provided information. The applicant has attached various supporting documents, including mark sheets and certificates, for verification.

Uploaded by

sushantakumarj17
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. : 27-24


Application no. : NRHM_SCC_76293
Applied Date : 10/10/2024
Name of the Post : State Cold Chain Manager
Applied for State/District : Odisha
PERSONAL DETAILS :
1. Applicant Name : SUSHANTA KUMAR JENA
2. Father's Name : SHANKAR KUMAR JENA
3. Date Of Birth : 03/01/1997
4. Mobile No. : 6370017549 5. Email Address : sushantakumarj18@[Link]
6. Gender : Male 7. Age as on : 27 Years 8 Months 28 Days
8. Category : SEBC 9. Physically Challenged : No
10. District of Domicile : Balasore
: Nampo, : Nampo,
11. Present Contact Address jaleswar,Balasore,Odisha,Pin- 12. Permanent Contact Address jaleswar,Balasore,Odisha,Pin-
756034 756034

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
Fakir Mohan
Degree 2018 May 1400 808 57.71 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

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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