|
1. Name (In Block letters) : |
____________________________________ |
Paste
Recent
Photograph
|
|
2. Age with date of birth (In Christian Era) :
|
____________________________________ |
|
3. Father’s/Husband’s Name : |
____________________________________ |
|
4. Complete Present Address for communication
with Pin Code : |
____________________________________ |
|
4.1 Telephone Number (Residence) |
____________________________________ |
|
4.2 Mobile Number. |
____________________________________ |
|
4.3 E-mail Address if any |
____________________________________ |
|
5. Complete Permanent Address with Pin Code :
|
____________________________________ |
|
5.1 Telephone Number (Residence) |
____________________________________ |
|
6. Name & Complete Address of Hospital/ Institution
where working : |
____________________________________ |
|
6.1 Telephone Number (Office) |
____________________________________ |
|
6.2 E- Mail Address if any |
____________________________________ |
|
7. Post held at present : |
____________________________________ |
|
8. Whether retired if so, the date of retirement
: |
____________________________________ |
|
9. Post held at the time of retirement : |
____________________________________ |
|
10. Details of experience in nursing services
: |
____________________________________ |
|
11. Academic Qualifications : |
____________________________________ |
|
12. Professional qualifications : |
____________________________________ |
|
13. Membership with professional organization
: |
____________________________________ |
|
14. Any other : |
____________________________________ |
|
15. Resume of the Applicant as per Annexure III
|
____________________________________ |
|
Signature of the applicant : |
____________________________________ |
|
Recommended by - Nursing Superintendent/Principal/District
Medical Officer/District Public Health Nursing
Officer etc. |
|
|
|
|
Place & date |
Signature & Seal |
|
Forwarded by Secretary, Health & FW (State Selection Committee for the Awards) |
|
|
|
|
Place & date
|
Signature & Seal |
