1
NATIONAL INSTITUTE OF HEALTH AND FAMILY WELFARE
Baba Gangnath Marg, Munirka, New Delhi-110067
Advertisement No. A.12025/3/2011-Admn.-II
Note: 1. The Application should be sent only in the prescribed format supported by
attested copies of testimonials.
2. Fill in all the information in block letters only.
1. Post applied for
:__________________________________________
Applicant should
affix his / her
recent passport
size photograph,
duly attested by a
gazetted officer
2. Details of Application : (a) Rs.____________________________________
fee
(b) Demand draft no.:________________________
(c) Date: __________________________________
(d) Name of issuing Bank & Branch: ______________________
_________________________________________________
(e) Exempted from the payment of fee : Yes/No _____________
3. Name of the applicant :_____________________________________________________
(In Block Letters)
First
Middle
Last
4. Fathers/Husbands name:__________________________________________________
(In Block Letters)
5. (a) Date of Birth (in figure):_________________________________________________
(b) Age as on 02.03.2012:________Years _______Months ________Days
(c) Whether claim for age relaxation (Yes/No):___________________________________
6. (a) Social Category
:_____________________________________________________
(SC/ST/OBC/PH/GEN/Ex-Serviceman)
(Please attach attested photocopy of the certificate)
(b) (i) If Physical Handicapped (Nature of Disability)(VH/OH/HH):_________________
(ii) Percentage of Disability:______________________________________________
(Please attach attested photocopy of the certificate)
(c) Whether Ex-serviceman:__________________ Date of Retirement:______________
(Please attach attested photocopy of the certificate)
7. Gender (Male/Female) :_____________________________________________________
8. Marital Status (Married/Unmarried/Divorcee etc.) :______________________________________
9. (a) Telephone no. (with STD Code):_____________________ (b) Mobile no. _________________
(c) Email ID
:_____________________________________________________
10. Present Address
:_____________________________________________________
_____________________________________________________
_____________________________________________________
Pin Code:_____________________________________________
11. Permanent Address
:_____________________________________________________
_____________________________________________________
_____________________________________________________
Pin Code:_____________________________________________
12. Nationality
:________________ 13. Religion
:_______________________
14. Educational/academic qualification starting with matriculation :
(Please attach separate sheet, if required)
Examination
University /
Year of
/Degree
Board
Passing
% age of
marks /
Division
Subjects
15. Technical/Professional qualification: (Please attach separate sheet, if required)
Examination
/Degree
University /
Board
Year of
Passing
% age of
marks /
Division
Subjects
16. Experience (Please attach attested copies of the experience certificates) (please start with the latest)
(Please attach separate sheet, if required):
Name of employer
Post held
Period
From
To
Pay Scale/Pay Band
& Grade Pay with
Basic Pay
Nature of work
/duties
17. Name of the employment exchange and registration no.
if any: _____________________________________________________________________
18. Typing Speed, where applicable
: English ______W.P.M. Hindi_______W.P.M.
19. Stenographic Speed, where applicable
: English ______W.P.M. Hindi_______W.P.M.
20. Working knowledge of computers
:______________________________________
21. Are you applying through proper channel (Yes/No) : _________________________________
If yes is this your advance copy? (Yes/No) :______________________________________
22. Any additional information
:______________________________________
Declaration
I hereby declare that I am a citizen of India and all the statements made in this application are true, complete and
correct to the best of my knowledge and belief. I have never been convicted by any court of law and no criminal case is
pending against me in any court of law in the country. My certificates can be got verified at any time from the issuing
authority. In the event of any information being found false/incorrect or ineligibility being detected before or after the
written test/skill test, my candidature will stand automatically cancelled.
Place:
Date:
(Signature of the Candidate)
Name:__________________
NATIONAL INSTITUTE OF HEALTH AND FAMILY WELFARE
Baba Gangnath Marg, Munirka, New Delhi-110067
Advertisement No. A.12025/3/2011-Admn.-II
Admit Card
(To be filled by the candidate)
1. Post applied for
:________________________________
2. Name of the applicant
:________________________________
(In Block Letters)
3. Fathers/Husbands name :________________________________
(In Block Letters)
4. Date of Birth
5. Gender (Male/Female)
Applicant should
affix his / her
recent passport
size photograph,
duly attested by
a gazetted officer
:________________________________
:________________________________
6. Present Address
:________________________________
(With name in Block Letters) ________________________________
________________________________
Pin Code: ______________
7. Signature of candidate
:________________________________
________________________________________________________________________________
(For office use only)
Roll no.
:___________________
Name & Address of Centre:
Certificate by Head of Department/Organization
(Applicable only to those candidates who are working in Govt./Semi.Govt/ PSU/Autonomous
Bodies and who are required to apply through proper channel)
1. Certified that Shri/Smt./Km/____________________________________ is an employee of
this deptt/office/organization. I have no objection to his/her application being considered for
the post.
2. Certified that particulars of the officer/employee have been verified and found to be correct.
3. It is certified that no disciplinary proceedings are either pending and/or contemplated
against the officer/employee. Integrity of the officer/employee is also certified.
4. Certified
also
that
he/she
submitted
his/her
application
to
the
department/office/institute/organization on _____________ for onward transmission to the
NIHFW.
Date:
Signature of Head of Department
(With Stamp)
Place:
Designation ______________
(Ministry/ Office stamp)
