Bheln
Bheln
Bheln
Experience
Required
Minimum 3
years
Duration
of
Work
Two visits per
month on
working days,
with a duration
of 3 Hrs per
visit.
Orthopedics
MS
(Orthopedics)
Minimum 5
years
Urology
MS MCH
(Urology)
Minimum 3
years
Gynecology
MD
(Gynecology)
Minimum 5
years
General
surgeon
MD/ MS
(General
surgeon)
Minimum 5
years
APPLICATION FORM
(To be filled by the Candidate)
2. FATHERS NAME
3. DATE OF BITH
D
M M
5. EX-SERVICEMEN? YES/NO
CATEGORY
(GEN/SC/ST/OBC)
%AGE
YEAR OF
SERVICE
6. ADDRESS OF CORRESONDENCE :
7. EDUCATION QUALIFICATIONS:
Sl No
1
2
Exam Passed
YEAR OF
PASSING
University/board
% of marks
Exam Passed
% of marks
2
3
8.Details of employment:
NAME &
ADDRESS
OF
EMPLOYEER
PRIVATE
ORG/GOVT
ORG/SEMI
GOVT
ORG/OTHER
TYPE OF
DESIGNATION/ PERIOD
ENGAGEMENT
AREA OF
FROM
(REGULAR/CONTRACT/ WORK
AD HOC/ PRVATE
PRACTICE)
PERIOD
TO
STATUS OF EMPLOYMENT
B.
10.
11.
E-mail ID
DECLARATION
I hereby declare that all the statements made by me in this application are true and correct to the best of
my knowledge and belief. I further undertake that in the events of particulars or information furnished by
me are found incorrect /unfilled, my candidature for the post is liable to be rejected or cancelled. If any
information is found to be false after appointment, then my services are liable to be terminated summarily.
DATE
PLACE .
SIGNATURE
.
NAME .