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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 should be self attested and a copy of online submitted application form / Receipt
Applying for Post*
Personal Details
Applicant's Name*
Father's/Husband's Name*
Mother's Name*
Domicile of MP:*
Category:*
Note:-OBC Creamy Layer candidate apply as UR.
Nationality:*
Gender*
Date of Birth(DD/MM/YYYY)* (In DD/MM/YYYY) Age as on 01/01/2021    - -(yy-mm-dd)
Marital Status* Marriage Date* (In DD/MM/YYYY)
More than one married candidate will not be eligible if the first marriage is not severed or died.
No. of Children Last child birth date (In DD/MM/YYYY) Is Your Last Child Born Twins
Are you working in government / corporation / board / autonomous institution staff / City Soldier?*
Are You an Ex Serviceman*
Are You Physically Handicapped ?*
Type Of Physically Handicapped
Handicap Percentage
Educational Qualification (Kindly attached self attested photocopies of all Mark Sheets and Documents.)
Qualification Name of Certificate/Diploma/Degree Passing Year (YYYY) University/Board Institute/College Name Obtained Percentage (In 00.00 Format)
10th* 10th
12th*
Qualification obtained*
Post Graduation
For GNM, It is Compulsory to add internship marks for calculation of percentage.
Do You have alive registration in MP nurses council Bhopal*
If yes,Registration No.
* 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%.
Have you ever worked as Samvidha employee on the same post?*
SnoDepartment NameFrom Date (In DD/MM/YYYY)To Date (In DD/MM/YYYY)Year (yy/mm/dd)
1
    
Total Experience(yy/mm) -
Communication Address
Address* State*
District Name* Division*
Pin No.*
Email id* Mobile No.*   Phone No.  
Permanent Address(Same as Communication Address)
Address* State*
District Name* Division*
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
Declaration *
I HEREBY DECLARE THAT ALL THE INFORMATION GIVEN IN THE AFOREMENTIONED APPLICATION FORMAT IS TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERTAKE AND ACCEPT THAT IF ANY OF THE INFORMATION GIVEN BY ME IS FOUND TO BE INCORRECT, THEN MY APPLICATION WILL BE REJECTED AND IF APPOINTED, THEN MY APPOINTMENT WILL BE TERMINATED & ACTION MAY BE TAKEN ACCORDINGLY.