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Application for the post of Medical Officer Jr. Class-I

Ad hoc Basis for the year 2014-15
:
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1.

Name of the Candidate ( In Block Capitals )

2.

Fathers Name

3.

a. Present Address( address for communication):

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b. Contact No. (Telephone / Mobile)

c. E-mail ID

4.

:
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Permanent Address

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5.

Affix self
signed
passport size
photograph

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Date of Birth recorded in the Matriculation or equivalent examination. dd.........mm..........yy..............

.....

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Day
....... Month.Year..................................(
In Words )
6.

Gender ( Please put \/ mark in the box ) : Male

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7.

Female

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Category ( SC / ST / SEBC / Un-reserve ) :

If reserve category mention Misc. Case No........................... Date of Issue................

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8. Religion :

9. Nationality :

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10. Whether an Ex-Service man ( Please put \/) : Yes

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No

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If yes, mention the period of service rendered in armed forces .........................................

11. Whether physically challenged :Yes

No

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Percentage of Disability............
12. Whether Sports Person ( Yes / No ) :

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13.
Marital Status ( Please put \/) : Married
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Unmarried
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14.
Knowledge in Odiya : The candidates must be ablehttp://www.jlatest.com/
to speak , read and write Odiya and should
have passed with Odiya as a Language subject in the Middle English School Standard or any
equivalent examination or pass a test in Odiya language equivalent to M.E School standard
conducted by the School and Mass Education Department, Odisha
15. Give particulars of examinations passed :
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Examination
Passed

Board/
School/
Council /
College /
University / Institution
Examination from which
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Body
passed

Total Marks of
Total Marks
% of marks
examination
secured in the secured without
appeared without
examination
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optional
without extra
back papers
optional/ back
papers
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3
4
5
6

1
2
H.S.C or
equivalent
+2 Science or
equivalent
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1st MBBS

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2nd MBBS
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MBBS

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Final MBBS

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16. Date of Completion of the Internship

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17. Odisha Council of Medical Registration No.

18.
Are you working presently under H&FW Deptt. Odisha ?If so, furnish particular.
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Name of the
District

Present place of Date of Joining

Nature of
posting
employment
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( Contractual /
Adhoc)

Order No. and Date

of the appointment

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19. List of enclosures Self attested Photo copies, submitted
by the candidate :
Sl No

Name of the Certificate

Please put \/

1
Recent Passport size photo ( affix )
2
Matriculation or equivalent
passed Certificate
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3
+2 or equivalent passed certificate
4
MBBS passed Certificate
5
Matriculation or equivalent Mark sheet
6
Conversion marks against grades if applicable
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7
+2 or equivalent Mark sheet
8
1st year MBBS Mark Sheet
9
2nd Year MBBS Mark Sheet
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10
3rd Year MBBS Mark Sheet
11
Final MBBS Mark sheet
12
Conversion mark sheet issued by the institution ( for foreign pass out
students )
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13
Odiya Pass certificate as per requirement http://www.jlatest.com/
14
Registration certificate/ receipt issued by Odisha Medical Council
subject to submission of Registration Certificate at the time of
verification.
15
Internship completion certificate
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16
Service certificate ( for in-service candidate )
17
Recent valid caste certificate from competent authority for reserve
category
18
Certificate from competent authority in support of sports person
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19
Disability certificate in support of candidate under disability category
20
Any other certificate as per requirement

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N:B- Please put the above Serial number on the right top corner of each above certificate
submitted .

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Declaration
This is to certify that all statements made in this application are true, completed and correct
to the best of my knowledge and belief. In the event of information being false or incorrect, or
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ineligibility being detected before or after the recruitment, action can be taken against me by the
authority as deemed proper.
Date :

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Full signature of candidate

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Place :