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H.No: Village: Mandal: District: Mobile

This document is an application form for admission to the Multipurpose Health Workers (Female) Training Course in Andhra Pradesh for the year 2018-2019. The form requests information such as the applicant's name, father/guardian's name, date of birth, educational qualifications, marks obtained, residential address, social status, and bank draft details. The applicant must declare that the information provided is true and submit documents such as academic certificates, residence proof, caste certificate, and photos along with the completed form.

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lakshman777
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102 views

H.No: Village: Mandal: District: Mobile

This document is an application form for admission to the Multipurpose Health Workers (Female) Training Course in Andhra Pradesh for the year 2018-2019. The form requests information such as the applicant's name, father/guardian's name, date of birth, educational qualifications, marks obtained, residential address, social status, and bank draft details. The applicant must declare that the information provided is true and submit documents such as academic certificates, residence proof, caste certificate, and photos along with the completed form.

Uploaded by

lakshman777
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GOVERNMENT OF ANDHRA PRADESH

APPLICATION FORM FOR ADMISSION INTO MULTIPURPOSE HEALTH WORKERS


(FEMALE) TRAINING COURSE IN GOVERNMENT / GRANT-IN-AID / PRIVATE TRAINING
INSTITUTIONS FOR THE YEAR 2018 – 2019

APPLICATION NO:

DATE:

1.Name of the candidate


(as per SSC Certificate)

2.Name of the Father / Guardian

3.Postal Address H.No:


Village:
Mandal:
District:
Mobile:

4.Date of Birth

5.Age as on 31.12.2017

6.Nationality

7.Religion

8.Social Status (SC/ST/BC/OC)

9.Native district:

10.State

11.Mother Tongue

12.Seat Category
a)Convener Free Seat
b)Management Seat
13.Name of the District
& Institution selected for
MPHW (F) Trg. Course

14.Educational Qualification

15.Qualifying Exam HT No

16.First appearance of qualifying exam (month) Year

17.Completed qualifying exam(month) Year

18.Marks obtained in 10+2 or Equivalent Exam:

Obtained
18.A. Sl. No. Subject Max. marks Result
marks
1

18.B. Particulars of study - Details for the four / seven consecutive academic years
ending with the moth and year of qualifying Examination

District in which
Academic
Class Studied Name of the School/Place the school is
Year
situated

19.Local Area
20.Details of Bank Draft enclosed Name of the bank
Branch
Date
Amount

DECLARATION

I hereby solemnly and sincerely affirm that the information furnished by me in the
application form and also in the enclosures submitted by me are true and correct. I have not
kept any information secret if it may be found false in future, I realize that I am liable to criminal
prosecution and also agree to fore go my seat.

Signature of Parent / guardian Signature of Candidate

Documents to be submitted along with the application form

1. Attested Copy of the SSC Certificate or any equivalent examination showing identity of
the date of birth of the candidate.
2. Attested Copy of the Intermediate certificate showing of marks obtained in the qualifying
examination.
3. Attested Copy of the Study/School Bonafied Certificate from 6th to Intermediate.
4. 7 years residence certificate by the candidates claiming eligibility as a local candidate
by the virtue of residence. (Nativity Certificate)
5. Bank Draft for Rs. 50/- in original ( In Favour of Commissioner Health & Family
Welfare, A.P., Gollapudi,Amaravathi.) payable at Gollapudi.
6. Certificate of social status in case of candidates belonging to SC/ST/BC.
7. Attested copy of the transfer certificate from the institution in which the candidate last
studied.
8. Two Self addressed medium size envelop with postal stamps worth Rs. 30/-
9. Three pass port size photos duly attested by Gazetted officer

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