APPLICATION FORM Jharkhand Rural Health Mission Society Department of Health, Medical Education & Family Welfare Post Applied for: Community Health Officer (CHO) Personal Details: Applicant’s Name with Title: Date of Birth: Father’s/ Husband Date Year Name: Gender (M/F): Mobile Number: Email ID (if available): Alternate Contact No Permanent Residence State: Jharkhand: Note: Candidates from state of Jharkhand need to furnish their permanent residence Certificate (For employment purpose) issued by competent authority of Jharkhand (not Other: less than Sub-Divisional Magistrate) Category: General: ST: SC: BC-I: BC-II Note: Candidates applying under reserved category shall need to attach a copy of latest caste certificate issued by competent authority (not below then Sub-Divisional Magistrate), to be duly attested by a Gazetted Officer. Are you falling in the category of Physically handicapped? NA: OH: VH: HH: Others NA- Not Applicable; OH Orthopedically handicapped; HH hearing handicapped; – ‐ VH‐ visually handicapped Disability Percentage: Candidates falling under the category of Physically handicapped need to attach PH certificate issued by competent authority, to be duly attested by a Gazetted Officer. [Applicable for PH Candidate] Please also mentioned disability% as indicated in PH certificate. Address: Correspondence/ Current Address with Pin Code Permanent Address with Pin Code PIN Code: PIN Code: Educational Details (Please attach self-attested copies of relevant certificates/ mark sheets): (a) All educational qualification details starting from highest qualification up to matriculation to be mentioned (b) Duly signed copies of all the certificates and marksheets of each qualification as filled by candidates to be enclosed. Examination Name of the Board/ University/ Mode of Course Course Passing Mark % Passed Course, Institute (Regular/ Other) Duration Month & (GNM/ B.Sc. Nursing Specialization & Year Details) Principal Subjects
APPLICATION FORM Jharkhand Rural Health Mission Society Department of Health, Medical Education & Family Welfare Post Applied for: Community Health Officer (CHO) Personal Details: Applicant’s Name with Title: Date of Birth: Date Year Father’s/ Husband Name: Gender (M/F): Mobile Number: Email ID (if available): Alternate Contact No Permanent Residence State: Note: Candidates from state of Jharkhand need to furnish their permanent residence Certificate (For employment purpose) issued by competent authority of Jharkhand (not less than Sub-Divisional Magistrate) Jharkhand: Other: Category: Note: Candidates applying under reserved category shall need to attach a copy of latest caste certificate issued by competent authority (not below then Sub-Divisional Magistrate), to be duly attested by a Gazetted Officer. General: ST: SC: BC-I: BC-II Are you falling in the category of Physically handicapped? NA- Not Applicable; OH – Orthopedically handicapped; HH ‐ hearing handicapped; VH‐ visually handicapped Candidates falling under the category of Physically handicapped need to attach PH certificate issued by competent authority, to be duly attested by a Gazetted Officer. Please also mentioned disability% as indicated in PH certificate. NA: OH: VH: HH: Others Disability Percentage: [Applicable for PH Candidate] Address: Correspondence/ Current Address with Pin Code Permanent Address with Pin Code PIN Code: PIN Code: Educational Details (Please attach self-attested copies of relevant certificates/ mark sheets): (a) All educational qualification details starting from highest qualification up to matriculation to be mentioned (b) Duly signed copies of all the certificates and marksheets of each qualification as filled by candidates to be enclosed. Examination Passed (GNM/ B.Sc. Nursing Details) Name of the Course, Specialization & Principal Subjects Board/ University/ Institute Mode of Course (Regular/ Other) Course Duration Passing Month & Year Mark %