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FSDFD
FSDFD
REGISTRATION NO.__________
(Pl write your Reg No. genearated at the time of apply)
JOB INFORMATION
POSTAL ADDRESS
PERMANENT ADDRESS
ACADEMIC EDUCATION
SSC
HSSC Level
Graduation
Post Graduation
Others
Duration Supervisor
Employer / Post / Position Job Description & Work Nature of Job Reason for
Name/Phone# / Salary
Organization held From To Responsibilities (Regular / Contract) Leaving
Desig.
Hepatitis B, C, HIV-AIDS, Diabetes, Hypertension, Deafness, Color Blindness, Drug Addiction, Epilepsy (Mirgi), Head Injury (Any other Disease)
Have you ever been declared Medically Unfit? Yes / No Reason for Unfitness
I _______________________ S/D/O _____________________ hereby certify and solemnly affirm that the above information provided is
correct to the best of my knowledge. I may be disqualified at any stage if any of the above information found incorrect.
APPLICATION FORM
Date Applicant Signature _________________________