WEST BENGAL STATE HEALTH & FAMILY WELFARE SAMITI Notice

Application for the post of ::Application Form(in BLOCK letters)…………………………………………………………………..Particulars of the Candidate:• Name in Full (in BLOCK letters) :: …………………………………………………………………Affix RecentPassport SizePhotograph• Father’s / Husband’s Name: :: …………………………………………………………………Mailing Address:• Village/ City :: ………………………………………………………………………………………………….• Police Station :: ……………………………………… ¯ District :: ………………………………..........• State :: ……………………………………… ¯ Pin Code :: ...…………………………..........• Telephone No. with STD Code: :: ……………………………………… ¯ Mobile No. :: …...……………………..........• E-Mail ID (if any) :: ……………………………………………………………………………………………..........Permanent Address:• Village/ City :: ………………………………………………………………………………………………….• Police Station :: ……………………………………… ¯ District :: ………………………………..........• State :: ……………………………………… ¯ Pin Code :: ...…………………………..........Sl.No.1.• Nationality: ‘INDIAN’ [‘Yes’ / ‘No’] :: ……………………………………………………………………………………………..........• Sex: [Male / Female] :: ………………………….… ¯ Religion :: ……………..…………………………..........• Date of Birth [DD – MM – YYYY] :: …………………………… ¯ Age as on [31 st August 2011] :: ………..………• Educational Qualification:Examination Passed Year Board / University TotalmarksobtainedDivision / Class% ofMarks2.3.4.5.6.1