PHOTO

GRAPH

BURNPUR HOSPITAL, SAIL – ISP, BURNPUR – 713325.

PERSONAL DATA FORM (FOR Proficiency Trainee (Intern Paramedic))

(PLEASE FILL UP THE DETAILS IN CAPITAL LETTERS)

SL.NO. DETAILS
NAME DOB :
01.

02. FATHER’S NAME

03. MOTHER’S NAME

04. HUSBAND’S NAME

05. DATE OF BIRTH

PRESENT ADDRESS PERMANENT ADDRESS :

06.

07. MARITAL STATUS

CATEGORY (PLEASE Unreserved / SC / ST / OBC

08.
TICK)

09. MOBILE No(s)

10. E- MAIL ID

11 ACADEMIC BOARD/UNIV. YEAR OF SUBJECT PERCENTAGE

QUALIFICATION PASSING
10th

12th (HSC)
12 Name of the
course passed

13 B.Sc. / Diploma / SCHOOL/COLLEGE/UNIVERSITY MARKS NO.OF ATTEMPTS

Certificate Course OBTAINED
in Paramedical /PERCENTAGE

1st YEAR

2nd YEAR

3rd YEAR

Others

14 WHETHER HAVING ANY WORK EXPERIENCE (IN ANY YES / NO (PLEASE TICK)
OTHER HOSPITALS)
IF YES PROVIDE
DETAILS

Place : (SIGNATURE OF
CANDIDATE)
Date :