10/10/23, 1:30 PM Director General (Training)

DIRECTOR GENERAL (TRAINING)

Medical Health & Family Welfare, Govt. of U.P
APPLICATION FORM (Re Submitted)

CANDIDATE INFORMATION

ANM
Registration Number (पंजीकरण
ANM230726108681 Course (कोर्स): Training
संख्या)
Registration

Are you doing work In UP Health Department/NHM as ASHA worker/partner Employee from Last 5 Years?(क्या क्या आप यूपी
No
स्वास्थ्य विभाग/एनएचएम में पिछले 5 वर्षों से आशा कार्यकत्री/संगिनी कर्मचारी के रूप में काम कर रहे हैं?)

Dependent of Freedom Fighters or Ex-Servicemen (स्वतंत्रता संग्राम सेनानी के आश्रित अथवा भूतपूर्व सैनिक ): No

Applicant's Name (आवेदक का

Sushama Chauhan Gender (जेंडर): Female
नाम) :

Mobile Number (मोबाइल नंबर) : 6307030931 Alternate Mobile no. (वैकल्पिक कांटेक्ट नंबर) : 7052048038

Date Of Birth (जन्म की तारीख): 08/08/2005 Email Id (ईमेल आईडी ): mmmut61033@gmail.com

Father’s Name (पिता का नाम) : Ramjanm Chauhan Mother’s Name (माता का नाम) : Pramila Devi

Category(श्रेणी): OBC (NCL) Nationality (राष्ट्रीयता): India

Marital Status (वैवाहिक स्थिति): Unmarried Spouse Name (जीवनसाथी का नाम):

Are You domicile of U.P. (क्या Physical Disability (शासनादेश के अनुसार शारीरिक रूप से
Yes No
आप यूपी के मूल निवासी हैं) दिव्यांगता):

ID Proof Type (पहचान पत्र का

Aadhaar Card ID Proof Number (पहचान पत्र नंबर): 802058612387
प्रकार):

Bank Holder Name (बैंक धारक

Sushama Chauhan Bank Name (बैंक का नाम): State Bank Of India
का नाम):

IFSC Code (आईएफएससी कोड): SBIN0011250 Account Number (खाता संख्या): 37130452558

Permanent Address (स्थायी पता) Kor , Nakhatpur , Ghazipur , Ghazipur , GHAZIPUR , Uttar Pradesh , 233226

Communication Address (पत्र

Kor , Nakhatpur , Ghazipur , Ghazipur , GHAZIPUR , Uttar Pradesh , 233226
व्यहार का पता )

EDUCATIONAL DEATILS (शैक्षिक विवरण)

S.No. Examination Name Board Name (बोर्ड PASSING YEAR Roll No (रोल Certificate Serial No Marksheet Serial No Score type (स्कोर Score/CGPA (कु ल
(क्र.सं.) (परीक्षा का नाम) का नाम) (उत्तीर्ण वर्ष) नंबर) (सर्टिफिके ट सीरियल नंबर) (मार्क शीट सीरियल नंबर) प्रकार) प्रतिशत)

High school (हाई Uttar Pradesh

1 2019 2490665 H8456238 0754127 Percentage 532/600
स्कू ल ) Board

Intermediate Uttar Pradesh

2 2021 217010475 84073800 2556016 Percentage 402/500
(इंटरमीडिएट) Board

FEE DEPOSIT INFORMATION (शुल्क जमा विवरण )

Transaction Id (लेन-देन आईडी): ANM230726108681T240756115 Payment Amount (भुगतान राशि): 100.0

Payment Date (भुगतान तिथि): 28/07/2023 10:01 AM Payment Status (भुगतान की स्थिति): SUCCESS

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10/10/23, 1:30 PM Director General (Training)

S E L E C T E D C O L L E G E ( च य नि त कॉ ले ज )

Priority (वरीयता) College (महाविद्यालय)

1 ANMTC District Hospital Harra ki Chungi Azamgarh

2 ANMTC BRD Medical College campus Gorakhpur

3 ANMTC Cholapur, Varanasi

4 ANMTC Bada Gaon Varanasi

5 ANMTC Aliganj Luckonw

6 ANMTC Near Reserve Police Line Sultanpur

7 ANMTC Soraon, Prayagraj

8 ANMTC Karanjkala Jaunpur

9 ANMTC Moth Jhansi

10 ANMTC Leprosy Hospital Campus GT Road Kanpur

11 ANMTC Near District Women Hospital Lakhimpur

12 ANMTC Pilkua Hapur

13 ANMTC Fatehgarh Farrukhabad

14 ANMTC TB Hospital Campus Etawah

15 ANMTC Nehtaur Bijnor

16 ANMTC Near CMO Office Campus Basti

17 ANMTC Fatehganj Bareilly

18 ANMTC Charkhari Mohoba

19 ANMTC District Hospital Campus Mainpuri

20 ANMTC Near CMO Office Mathura

21 ANMTC Near District Hospital Meerut

22 ANMTC Near District Hospital Moradabad

23 ANMTC Kukra Block Muzzafarnagar

24 ANMTC Amariya Philibhit

25 ANMTC Near CMO Office Pratapgarh

26 ANMTC Near CMO Office Campus Raebareli

27 ANMTC Milak Rampur

28 ANMTC SVD Hospital Campus Saharanpur

29 ANMTC Near Sitapur Eye Hospital Sitapur

30 ANMTC Lodhipur Shahjahanpur

31 ANMTC Madhan Mirzapur

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10/10/23, 1:30 PM Director General (Training)

S E L E C T E D C O L L E G E ( च य नि त कॉ ले ज )

32 ANMTC Naraini Banda

33 ANMTC Ayodhya

34 ANMTC Bannadeyi Aligarh

35 ANMTC Halwai ki Bagichi Mathura Road Agra

I hereby certify that the information provided in form is true and correct to the best of my knowledge and belief . If any discrepancy or
incorrect in form, I will be responsible in my candidature may be reject. Blur and unreadable documents can not be acceptable.

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