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file2} !!5 -!6 / Lette r. 20 1 5
 GOVERNMENT OF MAHARASHTM
PUBLIC HEALTH DEPARTMENT 2017
(RECRUTTMENT OF MEDICAL OFFICER GROUP-A)
Post Applied For

Name
ln Marathi
Father s
/Guardians Recent passport size
Name Photograph
Mothers
Name

FatherOs
/Guardians
Occupation

Candidate Signature(in box)

Gender Marital
Status

Date of Birth Age as On

(10.07.2017)

Mother Tongue Email-lD

Contact and Marital Information

Correspondence Address

Correspondence Address in
Marathi

Permanent Address in Marathi

Whether Spouse working with Govt. Spouse Place

Department Of Posting

Profession of the Spouse

Reservation

Category Caste
Certificate

Caste Sub Caste

Non -Creamy Layer Certificate Annual
lncome

Social Reservation

Physically Handicapped

Fees Details:

Sr.No Demand Draft No. I Amount Bank Name

1

General Information
Possesses Adequate Knowledge to read,
write and speak Marathi Language
Date Of Completion of Compulsory
Rotating I nternship(dd I mmlyyyy)
Date Of Registration Date Of Renewal
Registration Number (lf any)
(dd/mm/wvv) (dd/mm/ww)
Has Successfully Completed MS-CIT ?

Preferred Area of Posting

MBBS Year wise Marks:

Year Marks Out of Marks

lstYear

2 "" Ygar

3'" Year

4rth Year

Total

Percentage Mark in MBBS

Has any other Post

Graduate Degree/Diploma
in Medicalsubiect
Subject
 @

Qualifying examination :

Sr.N Facult Program Specialization Board/ Passin Clas Total Total Perce
o University g Year s Marks Out of ntage
v
Obtained Marks

Exoerience:
Sr.N Post Organization Name Organization Address Nature of ls the office
o Held Appointme Institution
nt Owned by
Govt.of
Maharashtra

Sr.N Exact date to Total Period Scale of Basic Pay Nature of Reasons for
o be given (Year/Month/Days) Pay (ln Rs) Post Leaving along
(Form-To) with discharge
certificate

TotalExperience (A)Before essential Qualification

(B)After essential Qualification
(C) After hisher Qualification
Reouired Documents :

Sr.N Documents
o
,l

2
3
4
5
I her$y dechre that all the informatbn fumbhed by in me application fom ara true .compbte and concc*
to the of my know ledge and behatf :l do underctand that I nead to obtain and produce all the required
original certificate enlieted in the form bye me at the time of document vedfication .l understand that entriee
maOe Uye me in this application form are final and binding on me I further &dare that in the event any
information beino found false or inconect I shdl bG lisle for disquelificatlon ae mentioned in the notificatiol

Place:

Date: Signature of the Candidate

r.-i.;id'=i,.:r
 Affidavit
for the post
Affidavit to be furnished bye a person along with the Application
Oi nleOicat Officer MMHS'Group A lN the fursuance of the Advertisement
Number O1t2O15 Dated ..' """'published bySelection board
For Medical officer Recruitment Established by Public Health Dept'
Govt.of Maharashtra
t............... Son daughter /wife of
.aged about .........years resident of

Do hereby solemnly affirm / state on oath as under:

1..1 have bubmitted my application for the Post of
In oursuance of the Advertisement No.01/2015 dated

2.1 have read the provtsions in the Rules and Notification of the Selection Board
that I fulfill all
carefully and I hereby undertake to abide by them .l further declare
qualifications'
The conditions of etigioility regarding age limits .educational
Experience if any .concession etc prescribed for the Post herein above.

are true '

3. I hereby declare that allthe statements made in this application
correct to the best of my knowledge& belief .in the event of my
Complete'and
ineligible liable to be
Information being found false or incorrect or I am declared
dismissed From service

4.lf information given in this Affidavit on oath is found to be false i'e.not

Board 'l
Supported by Oocumentary proof at the time of verification by the Selection
examinations and selection processes of the
will be liable to be btacklisted and Debarred from all further
Selection Board :and liable for disciplinary proceedings if
already in Government Service

Place:

Date: Signature of DePonent

VERIFICATION

I the above named deponent do hereby verify and declare thal

the contents
Of this Affidavit are true and correct toine best of my knowledge and
belief'No
Part of it false
is and nothing material has been concealed therein.
Verified at "..........this ...."..'.""" """""day of """""""" "20""""'

Deponent

Notary