COM MON AP PLICATION FORM
CHIEF DISTRICT MEDICAL & PUBLTC HEALTH OFFICER, BARGARH
Post Applied for Advertisement No:
Recent color Passport
size Photograph
N.B. Candidate those who willapplyfor
to be pasted
multiple post they must have to submit
separate applicatio n, otherwise
(Not to be stapled
application will be rejected, nor to be pinned)
1. NAME OF THE APPLTCANT (in block Capital Letters):
2. FATHERS NAME (in block Capital Lerters) :
3. PRESENT coNTAcr ADDRESS: (should be fiiled up in capital Letter)
clo
Street Name
Village / Town Name
vial
Pin Code
Distri
Email lDl
Phone No. in use
WhatsApp No
4. PERMANENT CONTACT ADDRESS: (should be filled u p in Capital Lefter)
C/o
Street Name
Village / Town Name
Via
Pin Cod
Distri
Email lD
Phone No. in use
5. DATE OF BIRTH: i] 1! a.,$ Y Y \r'
6. AGE AS ON (0L.08.2025): YEARS MONTHS DAY
7. GENDER: (tick V in the ap propriate box)
MALE FEMALE OTHER
8. MARITAL STATUS MARRIED UNMARRIED
9lilsS*
L
10. EDUCATION QUALI FICATION :
Mark
lnstitute I Board & Year %
Location Total Marks Marks
11. EXPERIENCE:
Post Held From To Job Chart
Name of the Firm
ENCLOSTJRES:
t. All Academic Qualification Certificate & Marksheet (Self-Attested) as Per Advt.
2. Experience Certificate if any (Self Attested)
3. Other Document if anY.
4. Proof of ldentitY
5. Two Passport size PhotograPhs
DECLARATION
best of my
Declaration: I do hereby declare that the information furnished above are true to the
knowledge and belief and that, if at any stage, it is found that any of the above material
information is
false f incorrect or is suppressed by me, my candidature / appointment under odisha
State Health &
I also declare that I
Family Welfare Society (OSH&FWS), Odisha is Iiable to be rejected / terminated.
ground such
have never been disengaged from service under the OSH&FWS, odisha on administrative
as diso bed ience I poor perfo rma nces/ misbehav iour / cri mi na I activity etc.
Place:
Date: Signature of the Candidate in Full
1-0 II i:t ii1. t'':
