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SALARY RESERVATIONS
S. POST EDUCATIONAL PER Total Date of
QUALIFICATION VJ NT NT NT OB EW OPE
N. NAME MONTH POST SC ST SBC Walk-in-
(A) (B) (C) (D) C S N
In Rs. Interview
Junior
B.Sc.,
1 Lab 04 - 1 - - 1 - 2 9/07/2021
Technician DMLT 17000
Lab
12th Pass 15,500
Assistant 04 - 1 - - 1 - 2 9/07/2021
2
400/-
Ward Boy 7th Pass daily
3 06 - 1 1 - 1 1 2 9/07/2021
wages

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 NATIONAL HEALTH MISSION,
Application No. : COVID-19 RTPCR RECRUITMENT
(Office Use only) DISTRICT NASHIK PHOTO
Application Form

Applying Post Name :-___________________________________

(All fields in the forms are mandatory to be filled an Incomplete form submitted will be treated as rejected)

Name:

(in capital letters) (First Name Middle Name Last Name )

Father’s/Husband’s Name:

Date of Birth : Blood Group: Gender:

DD MM YYYY

Marital status : Existing NHM Employee Nationality:

(Yes/ No) :

Original Category : Applying for Category: Caste Certificate Attached :

Yes/No

Address/Contact Details: (Name of the District and Pin code is compulsory)

Address:

District :
State :
Pin:
Contact No:
E-Mail Id Correspondence:

Computer Proficiency:

Academic /Professional Educational all summary: (Starting form most recent)

From TO Degree/ University/ Specialization/ Final Year Total Final Year

(MM/YY) (MM/YY) Diploma Institute Subjects Marks & Percentage
Obtained Marks ( %)

Permanent Work Council Registration No: (As Applicable) (MO/SN/Pharmacist,etc) :-

Work/Experience Summary :( Starting form current/most recent)
Experience :

Sr. Form To Organization Designation Responsibilities

No (MM/YY)
(MM/YY) (Min.30 & Max.50 Words)

Total Experience (In Years & Months): Relevant Experience to the post applied

(In Years & Months):

Declaration:

I hereby declare that all statements made in the application are true, Complete and correct to the best of my
knowledge and belief. I understand that in the event of any information being found untrue/false/incorrect or I
do satisfy the eligibility criteria my candidature will be cancelled, without assigning any reason thereof. I have
read the content of the advertisement and agree to abide by the rules, regulations and procedures for
appointment to the post applied for.

Name:

Place:

Date : Signature
Disclaimer:
The applicants are required to submit the full filled application on the day of walk in Interview

Checklist for documents to be submitted :

1) Full filled Application form in the prescribed format.
2) For MO/SN/Pharmacist Valid registration certificate.(As Applicable) If not renewed, renewal receipt.
3) For age Proof – School Leaving Certificate/ 10th Passing Certificate / Domicile Certificate
4) Diploma, Degree & Master Degree – Only submit Last Year Certificate and Marksheet
5) If any post-graduation, Post-graduation certificate
6) Experience – Experience certificate as per mention in the form
7) Computer/ Typing Proficiency - MS- CIT/ DOEACC Course, English Typing, Marathi Typing- for the
Post if applicable.

(OFFICE USE ONLY)

Remark :-_______________________________________________________________________

Name of Authority:- Signature of Authority:-