DHS ASSAM

Name of the Candidate

Father's Name

Mother's Name

Father's/Mother's Address

Gender

Male Female

Are you Resident of Assam ?

YES

NO

Upload Permanent residentship certificate of Assam ?

Date of Birth

Age on 1st Jan-2017

Upload Date of Birth Certificate OR HSLC OR HSSLC Admit card

Place of Birth

Police Station

District

Other State

Other District

Present Address

Same as Present Address

Permanant Address

Mobile Number

Phone Number

E-Mail

Are you Citizen of India?

If 'Yes' how?

Religion

Are You Differently Abled (PH)?

Category

Last Examination Passed *	Name and Address of Educational Institution	Year of Passing	Upload Marksheet/Certificate
HSLC
HSSLC or Equivalent
GNM/B.Sc. Nursing (From Govt. recognized Institute only )

* Fill in the relevant fields only

Present Occupation (If Any)

Previous Appointment (If Any)

Employment Exchange Registration No.

Upload Certificate of Employment Exchange Registration No.

Family Annual Income

(Certificate from Gaon Panchayat/DC/SDO/Circle Officer to be furnished if called for )

Are you BPL card holder?

( if 'Yes' upload scanned copy of BPL certificate)

Upload BPL Certificate here.

Name of Treasury

Challan No

Date of payment

Amount paid

Upload Scan Copy of Challan.

Are you a temporary or retrenched personnel of a temporary Department of the Govt. of Assam

YES

NO

Are you trained in or a member of the N.C.C or Territorial Army or trained Home Guard and Civil defence volunteer?

YES

NO

Whether there is any Govt/Semi Govt employee in your family?

YES

NO

If ‘Yes’, Relationship, Name of Job, Pay drawn, Place of posting, Permanent/Temporary

Upload Nursing Registration Certificate authenticated by Registrar, Assam Nursing Council

Upload Certificate of Service / Experience in the Government sector including NHM etc.

Instruction For Photograph: Size of photograph must be less than 35 kb. Height of photograph must be between 250 pixel and 320 pixel. width of photograph must be between 150 pixel and 220 pixel.	Upload Photo
Instruction For Signature Size of signature must be less than 30 kb. Height of signature must be between 100 pixel and 180 pixel. width of signature must be between 150 pixel and 220 pixel.	Upload Sign

Password (minimum 8 characters maximum 12 characters)

Re-Enter Password

Declaration

I am a candidate for the post of GNM and the facts stated above are true to the best of my knowledge and belief. In case of a false statement ,I am liable to any action Govt. may deem fit and proper.