Government of the People's Republic of Bangladesh

Bangladesh Public Service Commission Applicant's Copy

Application Form for Non-Cadre Examination [BPSC Form - 5 A]
Application for Ministry of Health and Family Welfare

User ID: NQTKRVCHXK Ref: 08-22/2022 | Last Date: 30 May 2022

Registration No 011258
Post Name Senior Staff Nurse
Exam Centre DHAKA
Applicant's Name RUMA KHATUN
Father's Name MD. KIBRIA MOLLA
Mother's Name REKHA BEGUM
Date of Birth 05 May 1994 [27 Years 10 Months 28 Days]
Gender Female

Freedom Fighter Status Non Freedom Fighter Ethnic Minority No

Marital Status Single Physically Handicapped No
Nationality/NID Bangladeshi/5084388049 Home District Magura

Present Address: Permanent Address:

Care of: MD. KIBRIA MOLLA Care of: MD. KIBRIA MOLLA
Village/Town: RAMANANDKATHI Village/Town: RAMANANDKATHI
Post Office: GORER HUT Post Office: GORER HUT
Post Code: 7620 Post Code: 7620
Upazilla/Thana: Shalikha Upazilla/Thana: Shalikha
District: Magura District: Magura

Academic Qualifications:

Examination Board/Institute Group/Subject/Degree Result Year Roll Duration

S.S.C Jessore Business Studies 4.31 2010 464626 N/A

Bangladesh Nursing and Midwifery
Diploma (Nursing/Midwifery) Nursing Science & Midwifery Passed 2017 39682 N/A
Council

Membership: (Registered Nurse from Bangladesh Nursing Council)

Association BNMC ID Number 39682

Experience:
Designation/Post Senior Staff Nurse [Grade: 10] Employed on Private Organisation
BIRDEM General Hospital
Salary 27000 [Pay Scale: 16000] Organization & Address
122 Kazi Nazrul Islam Ave, Dhaka 1000
Length of Service January 2021 to Till Date Total Experience 2 Year(s)

Enclosure: [Attested Certificates/Equivalent Certificates to be Submitted Later According to Tick Mark]

01. Recent Passpost Size Photograph | 02. Admit Card | 03. S. S. C. or Equivalent Certificate | 04. H. S. C. or Equivalent Certificate | 07. Diploma/Professional
Certificate | 11. Birth Registration Certificate | 12. National ID |
I declare that the information provided in this form are correct, true and complete to the best of my knowledge and belief. If any information is found
false, incorrect, incomplete or if any ineligibility is detected before or after the examination, any action can be taken against me by the Commission
including cancellation of my candidature.

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