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APPLICATION FORM
PERSONAL DETAILS
1. Post Applying For
*
:
--Select--
2. Applied For State
*
:
--Select--
3. Applicant Name (As in 10th Certificate)
*
:
4. Father's Name(As in 10th Certificate)
*
:
5. Date Of Birth
*
:
6. Mobile No.
*
:
7. Email Address
:
8. Gender
*
:
Gender
Male
Female
9. Age as on
:
10. Category
*
:
SC
ST
UR
SEBC
--Select--
11. Physically Challenged
:
No
Yes
12. District of Domicile
:
angul
Balasore
Bargarh
Bhadrak
Bolangir
Boudh
Cuttack
Deogarh
Dhenkanal
Gajapati
Ganjam
Jagatsinghpur
Jajpur
Jharsuguda
Kalahandi
Kandhamal
Kendrapara
Keonjhar
Khurda
Koraput
Malkangiri
Mayurbhanj
Nabarangapur
Nayagarh
Nuapada
Puri
Rayagada
Sambalpur
Sonepur
Sundargarh
--Select--
13. Present Contact Address
*
:
If same as present Address
14. Permanent Contact Address
*
:
15. QUALIFICATION DETAILS
Exam Passed
Name of Board/University
Year Of Passing
Month of Passing
Marks(excluding 4th optional)
Full Mark
Marks
Secured
Percentage
Duration Of Course
Full/Part Time
--Select--
Year
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Month
January
February
March
April
May
June
July
August
September
October
November
December
--Select--
Full Time
Part Time
16. Experience Details
Name of the Employer
Post Held
From Date
To Date
Salary
Whether OSH&FW Post
Description
Total Experience
Total Experience(Under OSH&FW Society)
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.
Accept
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