Application Cum CONCENT FORM For Working in High Priority FRUs

Name: Father's /Husband Name:
Caste Date Of Birth:   (dd/MM/yyyy)
Sex:    
Mobile No: Email ID:
PAN No: Adhar No:
Current Address:
Division: District:
Block: Address:
Permanent Address:
Education Qualification(regular course):
S.No. Qualification Details Institute/University Passing Year Result In% 
1 High School
2 Higher Secondary
3 MBBS
4 M.D./M.S. Diploma
 
M.P. Medical Council Reg.No. & Date
M.P. Medical Council Additional Reg. Date
Bond Completion Order No. Date
Choice of Institutions:
1. 2.
3. 4.
5:    
In case of alredy working candidates Regular/ Regular Contractual/NHM:
PSC Year & Merit No: Date of First Joining(dd/MM/yyyy):
Currently working as: Place of Posting:
Date of Posting at present posting place: Current Salary Details / Month:
       
Certification By CMHO
This is certify that the details, Submitted above by Mr./Ms ........................................................................
S/o ,W/O .............................................................................Posted as........................................................
At ........................................................................................Since..............................................................
        His current salary is ..............................(Basic+Grade Pay+allownces =Total). no complaint/ inquiry
/Legal Proceeding is pending against him/her.
Seal & Signature of CM&HO /BMO
Date:                                  
District:                                  
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