Public Service Commission U.P.

, PRAYAGRAJ
लोक सेवा आयोग उ0प्र0, प्रयागराज
Detailed Application Form ( विस्तृत आवेदन पत्र )

Notification Details ( Examination )

Advertisement Number : A-3/E-1/2023

Department/Directorate Name : MEDICAL EDUCATION AND TRANING DEPTT.

Applied for Post : STAFF NURSE (MALE),

Type of Recruitment : GENERAL RECTT.

Candidate's Personal Details

OTR Number : 493196057589 Application ID : 009171726000302

Candidate's Name : ABHAY RAJ UPADHYAY Father's/Husband's Name : SANAT KUMAR

Mother's Name : SAROJ Gender : Male
Date of Birth : 11/07/2000 Domicile of UP : Yes
Home State : UTTAR PRADESH Home District : CHITRAKUT
Category : General Marital Status : Married
Mobile Number : XXX-XXX-5349 Email-ID : ****[email protected]

Bank Transaction Details

Payment Gateway : State Bank Of India Payment Mode : INB
Fee Amount : Rs. 125.00 Transaction ID - Date: CPADCHLKL7 - 19/09/2023

Candidate's Other Details :

Are you Dependent of UP
No Are You Skilled Player of UP? : No
Freedom Fighter?
Are You Extra Ordinary Player
No Level of Player : ---
of UP?
Service Duration (Day-Month-
Are you UP Ex. Army? No 0-0-0
Year) :
Retirement Are you ECO/SSCO/CO of
--- No
Date(Date/Month/Year) : Army ?
Have your services been
Have you completed 5 year extended for rehabilitation and
No No
service ? no disciplinary action is
pending against you ?
Are You Physically
A). Are you Blind or Have
Handicapped (Divyangjan) of No No
Vision problem? :
Uttar Pradesh?
C). Have you any Physical
B). Are you Deaf or Have
No Problem (Locomoter disability No
hearing problem? :
or Cerebral Palsy)? :
D). Have you any Neurological
E). Have you Multiple Disabilities? : No
Problem? : No
Are You State Govt. Employee Service Duration (Day-Month-
No 0-0-0
of Uttar Pradesh ? : Year) :
Have you ever been Debarred Completion Date of Debarment
No N/A
from UPPSC ?: (DD/MM/YYYY) :
Basic Academic Qualification Details :

S No Examination Passed Board Name Year Of Passing Roll Number

UTTAR PRADESH BOARD OF HIGH SCHOOL AND
1. High School 2015 1707369
INTERMEDIATE EDUCATION

Essential Qualification Details

Evalation Type
Year Of Passing
Obtained Marks
Sr. No. Qualification AffirmationUniversity/Institute Cert/Roll Number
Total Mark
Issue Date
Percentage
1-Have passed High School
Examination with Science and
passed Intermediate
Examination of the Board of
High School and Intermediate
Education, Uttar Pradesh or an
Examination recognised by the
Government as equivalent
thereto. 2-Possess diploma in
General Nursing and Midwifery
N/A
or B.Sc Degree in Nursing
N/A
1. registrable with the U.P. Nurses Yes ---
N/A
and Midwives Council or N/A
N/A
Possess diploma in Psychiatry
registrable with the U.P. Nurses
and Midwives Council. 3-
Possess registration certificate
from U.P. Nurses and Midwives
Council as Nurse and Psychiatry
or possess registration certificate
as Nurse and Midwives from the
Uttar Pradesh Nurses and
Midwives council.

Candidate's Registration as Nurse & Midwife and Experience Details worked as on Contract basis ↓
Possess Registration Certificate as Nurse and Midwife from the Registration Number : 125805
Yes
Uttar Pradesh Nurses and Midwives Council : Registration Date [DD/MM/YYYY] : 31/03/2023
Working as Staff Nurse on contract basis in the Medical and
Total Experience as Nurse on Contract basis as on last date of
Health Services Department, Uttar Pradesh /Medical Education No -/-/-
Application Form Submission [Year-Month-Day] :
and Training Department, Uttar Pradesh :

Candidate's Permanent & Communication Address Details :

Permanent Address Correspondence/Mailing Address
Address (Line 1 2 3) : SANAT KUMARCHARAICHWARA Address (Line 1 2 3) : SANAT KUMARCHARAICHWARA
House No. : NA House No. : NA
Street No./PO : NA Street No./PO : NA
City Name : CHITRAKUT City Name : CHITRAKUT
State : UTTAR PRADESH State : UTTAR PRADESH
District Name : CHITRAKUT District Name : CHITRAKUT
PIN : 210205 PIN : 210205

I accept the following declaration : :Yes

1. I hereby declare that I have read all terms & conditions according to the advertisement and I accept it.
2. I hereby declare that all the entries/statements made in this application are true, complete and correct to the best of my knowledge and belief.
3. I under take that if any information furnished or documents submitted by me are found to be false or have been concealed, then my application/candidature is liable to
be rejected/cancelled by UPPSC.
Accepted : Application form has been Provisionally accepted. -
Application Form Submission Date : 19/09/2023 , Time : 21:19:05 Application Form printing Date & Time : [ 19/09/2023 ,21:19:10 ]