DIPHU ASSAM

Applied Post

Name of the Candidate

Father's Name

Mother's Name

Father's/Mother's Address

Gender

Male

Female

TransGender

Date of Birth

Age on 1st Jan-2019

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

PwD/Divyang

Category

Last Examination Passed *	Name and Address of Educational Institution	Year of Passing
Degree/Diploma/Certificate/Licence (in respective fields)
HSLC
HSSLC or Equivalent

* Fill in the relevant fields only

Present Occupation (If Any)

Previous Appointment (If Any)

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?

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

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Password (minimum 8 characters maximum 12 characters)

Re-Enter Password

Declaration

I am a candidate for the post of Staff Nurse 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.

Assam Hills Medical College and Research Institute, Diphu

Staff Nurse