Province Government

Gandaki Province
Ministry of Social Development Photo
Health Training Center
Pokhara, Kaski

Training Registration Form

Training Name:- Participant Trainer /Co-Trainer/Coordinator

Training Site: - Province/District :- Gandaki Province

Starting Date :-…………………………………..………….. Ending Date:-…………….…...……………. Fiscal Year:2077/2078

PERSONAL INFORMATION
Name (in Block Letter) :-……..………………………………………………………….…………………………………………………………….....

नेपालीमा(दे वनागरीक लिपी) ……………………………………………………………………………………………………………………………………

Sex:- Male Female Other(Specify)…………………………………

Date Of Birth (yyyy/mm/dd)( BS ):- ……………………………………………

PERMANENT ADDRESS CASTE:-

Province:-……….……………………District……………………………………………………………… Dalit JanjatiMadhesi Muslim

Brahmin/Kshetri Other
Rural/Municipality/Sub/Metropolitan:-………………………………… Ward No.:-…………...

Contact No.:- …………………………………………………………………………………….

Email:- ……………………………………………………………………………………………..

CADRE Sponsored:-

Medical:- Government
Nursing:-
Public Health:- Non Government(Specify):-……………………………………
Paramedics:-
AHW/ANM:- Self :-
Others (Specify):-
Others (Specify) :- ....……………………………………………………

……………………………..……….
7. Academic Qualification : -……………………………..……….
WORKING PLACE
WorkingOrganization:-………………………………………………………….……………………………………District…………….……………………………

Province:- ...................……………Rural/Municipality/Sub.Metro/Metropolitan:-...……………….…................................................

ContactNo.:-………………………………………..….…Designation:-……………….…………………..………….……………Level:-………………………

PIS. No.:- ……………...….…..…CitizenshipNo&IssuedDistrict .:-………………..……………..…Council Reg.No:-.…………..………...........

(नोट : फारम भर्दा आफ्नो नाम, ठे गाना ,संकेत नं , नागरीकता नं र सम्वन्धित स्वास्थ्य व्यवसायसी परिषद दर्ता नं अनिवार्य लेख्नु पर्ने छ।विवरण छुट भए प्रमाण पत्र उपलव्ध हुने छै न)

Participant’s Signature. …………………..…………………… Coordinator Name’s &Signature.…………………..…………………………….