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2020062934

The document is a notification from the Government of Andhra Pradesh for the application form for the posts of Staff Nurse, Pharmacist Gr-II, and Lab Technician Gr-II on a contract basis. It includes sections for personal details, educational background, requisite qualifications, and a declaration by the applicant. Additionally, it outlines the application fee payment details and requires a photograph to be affixed.

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VENKATA GOUTHAM VUTTI
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3 views

2020062934

The document is a notification from the Government of Andhra Pradesh for the application form for the posts of Staff Nurse, Pharmacist Gr-II, and Lab Technician Gr-II on a contract basis. It includes sections for personal details, educational background, requisite qualifications, and a declaration by the applicant. Additionally, it outlines the application fee payment details and requires a photograph to be affixed.

Uploaded by

VENKATA GOUTHAM VUTTI
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

DISTRICT MEDICAL & HEALTH OFFICER: KADAPA, YSR DISTRICT.


NOTIFICATION NO. 05/ 2020.

APPLICATON FORM
(For the Post of Staff Nurse/ Pharmacist Gr-II/
Lab Technician Gr-II on Contract Basis)
AFFIX PHOTOGRAPH
APPLICATION NO: HERE
(TO BE FILLED BY THE OFFICE)

APPLICATION FOR THE POST OF:

1. Name of the candidate:

2.a Name of the Father

Name of the Spouse


2.b
(If Married)

3. Gender

4. Date of Birth
Social Status
5. (OC/SC/ST/ BC-A,B,C,D,E)

6. Status (Local/Non Local)


Whether Physically
7. handicapped Specify details.
(VH / HH / OH)
Whether Sports if any
8.
details:
Whether working on Number of years of
Contract / Out Sourcing Service working in
Basis in any Government government
institutions under Medical institution ( M & H)
9
and Health Dept. (If yes
enclose Service Certificate
from the Concerned
Authority)
Whether Ex Service
10. YES / NO
man/woman

11. APPLICATION FEE: To the A/c. 067401001328, IFSC - ICIC0000674

Mode of Payment
Receipt / Counter Foil No. Amount (through Bank, Online /
UPI Transactions)

(Contd., P/2)
12. DETAILS OF SCHOOL EDUCATION:

Year of
Class Passing School & Place District

IV
V
VI
VII
VIII
IX
X

13. MARKS OBTAINED IN THE REQUISITE QUALIFICATION FOR THE POST OF STAFF NURSE /
PHARMACIST GR-II / LAB TECHNICIAN GR-II :

Marks obtained A.P.


Requisite Name of the Nursing /
Technical College & Pharmacy
Qualification University Max. Marks Council /
Year Para Medical
Marks obtained
Board
Regd. No.

Total

09. ADDRESS FOR COMMUNICATION ALONG WITH MOBILE NUMBER :


NAME :

Father’s / Husband’s Name :

Present Residential Address :

E-mail ID :

Mobile No. :

DECLARATION

I S/o. / D/o. certified that the


particulars given above are correct to the best of my knowledge and belief. I also agree that in
the event of any of the particulars furnish in my application being found to be incorrect or false
at a later date my appointment will be cancelled summarily.

SIGNATURE OF THE APPLICANT.

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