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DEPARTMENT OF PUBLIC HEALTH AND PREVENTIVE MEDICINE APPLICATION FOR THE POST OF MULTIPURPOSE HEALTH WORKER (MALE) (Health Inspector Grade-II) 1.Name in Block Letters (Initial at end) 2. Address for Communication (in Block Letters)
Affix recent passport size photograph (To be attested by a gazetted officer)
3. Name of the Parent / Guardian : 4. Date of Birth
Date
Month
Year
5. Age (as on 01/07/2016)
6. Religion
Hindu
Muslim
Christian
Others
MBC/DC
BC
( appropriately)
7. Mother Tongue 8. Nationality
Indian / Others
9. Native District 10. Community ( appropriately)
ST SC
SC(A)
11. Name of the Caste 12. Caste Code (As per Community Certificate) 13. Community Certificate Particulars: Sl.No. and Date of issue …………………………. Issuing Officer’s Designation
………………………….
Issuing Office
…………………………..
BC(M)
OC
14. Marital Status
: Unmarried / Married
15. Educational qualification particulars: Qualification
Institution
Total Marks Maximum Obtained Marks
% of Marks
Medium
SSLC HSC Diploma in Sanitary Inspector Course 16. Are you an Ex-service man
:
17. If yes, PPO No.
:
Yes / No
Payment details Bank Name
:
Branch Name
:
DD No.
:
Amount
:
Date:
Date : Station:
Signature of the candidate DECLARATION (To be filled by the candidate)
I,___________________________________S/o __________________________________ do hereby solemnly affirm that the statement made and information furnished in my application form and in all the enclosures thereto submitted by me are true. If it is found that any information furnished therein is false in particulars, or there has been suppression of facts, I know that I am liable for criminal prosecution and I also agree to forego my selection to the post of Multipurpose Health Worker (Male) (Health Inspector Grade-II).
Date:
Signature of the candidate
Annexure List of documents to be attached along with the application 1. Attested copy of :i. Evidence for Date of Birth (Birth Certificate/SSLC/HSC ) ii.
Mark sheet of SSLC
iii.
Mark sheet of HSC
iv.
Mark sheet of Diploma in Sanitary Inspector Course
v.
Evidence for Tamil Qualification (viz., SSLC / HSC Certificate for having passed in Tamil)
vi.
Community Certificate from the competent authority. (Permanent Community Certificate)
vii.
Certificate of character and conduct issued by Group A or Group B officers on or after issue of current notification.
viii.
Certificate of character and conduct issued by the Head of the institution in which last studied.
2. Demand Draft for the specified amount 3. Two (2) passport size colour photograph with the Name and Date of Birth written on the back side.
