APPLICATION FORM

Application no.

:NRHM_KEO_37607

Applied date

: 10/02/2015

PERSONAL DETAILS :
1. Name of the Post

: Work Consultant-Keonjhar

2. Applied for State/District

: Keonjhar

3. Applicant Name

: JAYASHREE GARNAIK

4. Father's Name

: AMIYA BHUSHAN GARNAIK

5. Date Of Birth

: 25/06/1993

6. District of Domicile

: Deogarh

7. Gender

: Female

8. Age as on

: 21 Years 6 Months 6 Days

9. Category

: SEBC

10. Physically Challenged

: No

11. Present Contact Address

: C/O-DR. SAMBIT KUMAR

PRADHAN, HOSPITAL LINE,
DEOGARH

12. Permanent Contact Address

: C/O-DR. SAMBIT KUMAR

PRADHAN, HOSPITAL LINE,
DEOGARH

13. Mobile No.

: 9437057198

14. Email Address

: drsambitmd@gmail.com

15. Language Spoken/Written

: Oriya, English, Hindi

16. Regd. No

: F0906001072

17. Name of Board

: S.C.T.E&V.T

QUALIFICATION DETAILS :
Name of
Exam Passed Board/Universit
y
Diploma

S.C.T.E&V.T

Year Of
Passing

Month Of
Passing

Full Mark

Marks Secured

Percentage

Duration Of
Course

Full/Part Time

2012

May

3700

3139

84.84

3 YRS

Full Time

EXPERIENCE DETAILS :
Name of the
Employer

Post Held

From Date

To Date

Year

Month

Job Description

Salary

Ms Arpita
Construction,
Bhadrak

JE

19/09/2012

29/08/2014

11

Site Supervision
& Billing

12000

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 (Attested copies):1.10th Mark Sheet and Certificate

2.Proof of M.E Odia passed certificate
3.+2 Mark Sheet and Certificate
4. Diploma Mark Sheet and Certificate
5.Degree Mark Sheet and Certificate
6.P.G. Degree Mark Sheet and Certificate
7.Valid Registration Certificate
8. No Objection Certificate from candidates working under Health Dept.
9. One Recent Passport size colour photograph
10.Valid Caste Certificate (for SC / ST candidates)
11.Experience Certificate, if any
12.Any Identity Proof