REGISTRATION / ROLL NO : DH177R7P52A3540

APPLICATION FOR THE POST OF

Staff Nurse (NUHM)
To,
The CMOH & Secretary, ( Advt. No. DHFWS/177/23 Dt.06/02/2023 )
DH&FW Samity, Jalpaiguri.
CMOH Office, 1st Floor
Dist. Health & Administrative
Building, Hospital Para
Jalpaiguri-735101

1. Name of Applicant: : HIMANI SARKAR 2. Father's / Husbands Name : : HARIPADA SARKAR

3. Permanent Address : BAMANTARI, DAUKIMARI, DHUPGURI, Jalpaiguri, 735210
4. Sex : Female 5. Date of Birth : 15 / 01 / 1999
6. Age as on 01/01/2023 : 23 yrs 11 months 16 days 7. Caste : SC A031789
8. Mobile No. : 7384085558 8389094863 9. Email ID : himanisarkar99@gmail.com
10. Application Fees Paid. : Rs. 50.00 on 22.02.2023 11. Bank Ref. : 305377122898
12. Two Wheeler D.L. Status : No
13. Registration Details : GNM 1111/OCT-2021/67B/NC WBNC
14. Essential Qualification & Others
Examination Passed Year of Board/ University/ Institution Type Total Marks Obtained % of
Passing (Excl Optional) (Excl Optional) Marks
Madhyamik (10th) 2014 WBBSE Regular 700 373 53.29
HS (10+2) 2016 WBCHSE Regular 500 430 86.00
GNM 2021 WBNC Regular 1600 1100 68.75

15. Computer Qualification

Examination Passed Board / Name of the Institution Year of Course
Passing Duration

16. Experience Details **

Sl Name of the Employer Institution Designation Dt. of Dt. of Total
No Status Joining Leaving Month
1. HERITAGE HOSPITAL Pvt STUFF NURSE 18/10/2021 05/02/2023 15
2.
3.
4.
5.
** In case of private experience, the certificate must be in the letterhead of the Employer / Pvt Institute, with Govt Registration No. of that institute, the salary statement
from that institute/ employer for whole experience period, the post held by the employee, the nature of work of that post must be written clearly with full signature, name and
valid contact no, email id of employer/office in charge /stakeholder of that institute must be clearly written.
This certificate must be authenticated by an GAZETTED officer with clear signature, name and official stamp, otherwise the experience certificates will be treated as invalid.

DECLARATION : I hereby solemnly declare that the information furnished above are based on material records and are true to the best of my
knowledge and belief. If any information furnished or any part of it is found to be incorrect my candidature is liable to be cancelled.

Print Date : 22/02/2023

:#: 103.211.132.161

Signature of the Applicant

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