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APPLICATION FORM FOR BLOCK PROGRAM MANAGER UNDER NHM

1

NAME OF THE DISTRICT APPLIED FOR:

NAME OF THE APPLICANT:

FATHER'S/HUSBAND'S NAME:

RESIDENTIAL ADDRESS:

PERMANENT ADDRESS:

MOBILE NUMBER:

EMAIL ID:

CASTE (ST/SC/OBC/UR):

DATE OF BIRTH:

10

11

12

EDUCATIONAL QUALIFICATION:
S.No Name of the
Essential Educational Qualification
University
(Fill in appropriate Column)
MBA
Master in
Master in
MPH
DPH MSW
Hosp. Mgt. Health Adm.

YEAR OF PASSING (Essential Educational

Qualification):

Aggregate (%) Total Score/No. of study

years for qualifying degree.

ESSENTIAL WORK EXPERIENCE (Post Qualification):

(Fill in appropriate column)
Minimum 1 Year of experience of working as Block Child Health Manager/working on
Managerial position at Block level (Post Qualification).
(
!
"#
$ %&
' ( )
*+ )
1 2 Years

13

PGDHHM

2 Year and above

3 Year and above

5 Year and above

COMPUTER PROFICIENCY (Relevant Documents if any): YES/NO

PGDCA
DCA
Certificate Course in Computers.

*Applicants can apply in any number of Districts.

Name and Signature of the Applicant:
Place and Date:

!
#

"

% &

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9 &

UR

UR

Jaithari

UR

UR

UR

UR

SC

UR

UR

10

UR

11

UR

12

UR

Sewada

13

UR

Toankkhurd

14

UR

Manawar

15

UR

Nalchha

16

UR

Tirla

17

UR

Shahpura

18

UR

19

UR

20

UR

21

UR

Ashok Nagar

"(J
"3 9(
"3 9(
$ (
H &
H6
7
%
%
%

2 (
2 (
%
%
"
%
"
%
"
%
"
B 3
B 3
B 3
5"( &
5"( &
5"( &
K "&

Balaghat
Bhainsdehi
Multai
Fanda
Nogoan
Sounsar
Damoh
Patera
Tendukheda

Dabra
Morar
Harda
Hoshangabad

22

UR

23

UR

24

UR

25

UR

26

UR

27

UR

28

UR

29

UR

30

UR

31

UR

32

UR

Badwara

33

UR

Dhimarkheda

34

UR

Khalwa

35

UR

Pandhana

36

UR

37

UR

38

UR

39

SC

(
(
(
(

Bankhedi
Seoni Malwa
Sohagpur
Indore
Depalpur
Sanwer
Panagar
Patan
Sihora
Ranapur

Bichhia
Bijadandi
Ghughri
Narayanganj

40

UR

41

UR

42

UR

43

UR

44

UR

45

UR

46

UR

47

UR

48

UR

Begumganj

49

SC

Sanchi

50

UR

51

UR

52

SC

Jawa

53

UR

Naigarhi

54

UR

Raipur Karchuliyan

55

UR

Kesli

56

UR

Malthona

57

UR

Uchehera

58

UR

59

UR

60

UR

61

UR

62

UR

63

UR

64

UR

65

UR

66

UR

67

UR

68

SC

69

UR

70

ST

71

UR

72

UR

73

UR

74

ST

75

UR

76

ST

77

UR

78

UR

79

ST

80

ST

81

UR

82

OBC

&3
&3

Bhanpura
Ambha
Porsa

% &
% &
% &
'
6

5 L7
5 L7

%
%
%
%
%

Babai Chichali
Gotegaon
Kareli
Neemuch
Ajaygarh

Rajgarh
Narsinggarh

Sehore
Astha
Budni
Ichchhawar
Nasrullaganj
Lakhanadon

% (
% (
&
&
&
&
&
&
&
3(
3(
3(
L7
L7
;M53
;M53
;M53

Beohari
Budhar
Shivpuri
Badarwas
Karera
Khaniadhana
Kolaras
Narwar
Pohari
Baidhan
Chitrangi
Devsar
Jatara
Palera
Badnagar
Ghatia
Mahidpur
Sironj

5"( &

Barela

/.

% &
#

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!

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(Block Program Manager)

*$

I+

*
AN
AN1C
+, ,,,

(
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8
&
&
(Monthly remunerations depicted in tabulation is subject to GoI approval)