GOVERNMENT OF TELANGANA

APPLICATION FOR RECRUITMENT UNDER NHM PROGRAMME -02/2024

KHAMMAM DISTRICT
REGISTRATION NUMBER
(TO BE FILLED BY THE OFFICE)
DATE :

APPLIED FOR THE POST OF:

QUALIFICATION :

Name of the Candidate

1
(as per SSC or equivalent
certificate)
2 Father/ Husband's Name

3 Sex (Male/Female)

4 Date of Birth (DD/MM/YEAR)

Social Status
5
(OC/BC-A/B/C/D/E, SC/ST)
Whether Physically
6
Handicapped
(If Yes, State HH/OH/VH)
7 Whether Ex-Servicemen /Women/NCC

Details of School Education. Name of the School Studied, Year and District
Year of
School Name & Village Erstwhile District Present District
Study

Class-I

Class-II

Class-III

Class-IV

Class-V

Class-VI

Class-VII

9 Qualification for applied post

10 Year of Passing

11 Registration Council Number

 Maximum Marks in the qualifying
12
examination

13 Total marks obtained

Marks obtained in groups (without

14
languages)
% of Marks obtained
15
(Without language)
Claculation of Marks obtained
16
for 90% (without languages)
Completed years of Age as on
17
01.07.2024

18 Weightage Marks 10% for Age

Total percentage of 100 %

19
(Col.N. 16 & 18)

Payment of Fee Rs 300/- details DD No : ………………………………….. Date : …………………………………..

20 (other than SC/ST/BC/EBC
CANDIDATES) Bank : ………………………………….. Branch : …………………………………..

H.No : ……………………………………………….

Street : ……………………………………………..
21 Address for Communication
Village/ Mandal : ……………………………..

District : ……………………………………………

22 Mobile Number

DECLARATION

I ……………………………………………………. S/o, D/o………………………………………. Certify that the above particulars furnished by me are correct to the
best of my knowledge. I also agree that in the event of any of the particulars furnished by me in application being found to be incorrect or
false at a later date, my candidature will be cancelled summarily.

Date : Signature of the Candidate

Place :
FOR OFFICE USE ONLY
verified by
(Candidates applying for)

Self attested copies of the following certificates should be enclosed alongwith the application form.

1 S.S.C or Equvivalent examination

2 Intermediate or 10+2 examination

3 Qualifying examination Pass certificate i.e GNM / B.Sc(Nursing)

4 Marks memo of all the years (qualifying examination)

5 Registration certificate of respective counsil

6 Latest Caste certificate issued by the Tahsildar / MRO concerned.

Study certificates for the years from 1 st class to 10 th class and in case of private study residence certificate from the Tahsildar/ MRO
7
concerned

8 PH certificate in respect of candidates claiming reservation under PH Quota

9 Relevant certificate in respect of candidates claiming ex-serviceman quota

10 1 Photograph duly pasted on the application form

11 Demand Draft for Rs 300/- in favour of DMHO Khammam (other than SC/ST/BC/EBC CANDIDATES)

12 Acknowledgement card

ACKNOWLEDGEMENT
Received application from Sri/Smt/Dr……………………………………………………...……………………….on .02.2024.

Reciever's signature