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Fields marked with * are mandatory
Instructions
Documents to be furnished in original at the time of verification of documents along with one set of photocopies attested by a Gazetted officer and a copy of online submitted application form / Receipt
Personal Details
Applying for Post *
Applicant's Name*
Father's/Husband's Name*
Mother's Name*
Category:*
Note:-OBC Creamy Layer candidate apply as UR.
Nationality:*
Gender*
Date of Birth(DD/MM/YYYY)* Age as on 01/01/2021
- -(yy-mm-dd)
Are You Physically Handicapped?*
Are you Domicile of MP? *
Are You an Ex Serviceman*
Type of Handicap?*
Marital Status
Marital Status:* Marriage Date (In DD/MM/YYYY)
No. of Children Last Child Birth Date (In DD/MM/YYYY)
Is Your Last Child Born Twins? Is Your Second Marriage
Note:- More than one married candidate will not be eligible if the first marriage is not severed or died.
Educational Qualification
Qualification Name of the Degree/Diploma Stream Passing Year(YYYY) University/Board Institute/College Name Obtained Percentage (00.00) Attempt
10th* 10th  
12th* Higher Secondary
Essential Qualification UG*
Additional Qualification
DM/MCH
Other 1
Other 2
Other 3
* In case your University/Institute does not award marks, please convert grades(CGPA) to Percentage marks and fill.
* Write % of marks with two digits after the decimal. The second digit after the decimal should be rounded off. e.g., if Marks is 60%, then write 60.00%. If marks are 68.938% then write 68.94%.
* In case PG degree is awarded. Marks were not given by university/college, Kindly choose option MD/MS awarded
Other Information
Medical Council Registration Number(M.B.B.S/MD/MS/MCH/DM)*
Are You Serving in Government/Corporation/Board/Autonomous Organizations? (If Yes so, the applicant NOC is compulsory to attach)*
Experience Details
Communication Address
Address*
State* City* Pin No.*
Email id* Mobile No.*   Phone No.  
Permanent Address(Same as Communication Address)
Address*
State* City* Pin No.*
Mobile No.* Phone No.
Bank Details
Account Number Bank Name
Account Holder Name IFSC Code
Attachment
Attach Photo with Signature*
Click here for photo sign format
Read form carefully before submission.
1. मै प्रमाणित करता/ करती हूँ कि मेरे द्वारा दी गई उपरोक्त जानकारी पूर्ण एवं सत्य है | जानकारी असत्य होने की दशा में आवेदन पत्र / नियुक्ति पत्र निरस्त क्या जा सकता है |
2. मै प्रमाणित करता/ करती हूँ कि मुझे नैतिक पतन के किसी अपराध में किसी न्यालय द्वारा न तो दोषी पाया गया है और न ही मेरे विरुद्ध इस प्रकार का प्रकरण किसी भी न्यालय में विचाराधीन है |