Bio-Data form for the post of Clinical Psychologist _/ Psychologist

(To be filled in by the candidate in BLOCK LETTER)

Self-attested

1.. Name of the Candidate:

Passport

1. Father's/Guardian's Name: _size
   
   
2. Date of birtht ......../..... _I . ... [DD/MM/YYYY) _photograph
   
   
3. ^Sex [Male/Female):
   
   
4. Caste & Categories: General/SC/ST/0BC-A /OBC-B/PH
   
   
5. Address: PermanentAddress: PresentAddress:
   
   

PIN: District:

7. Mobile Number:

08, Academic Qualification: Out ofTotal Marks

Madhyamik or Equiv.

H.S, or Equiv.

Graduation or Equiv.

M.A. _/ M.Sc

Any other qualification

_09, Year of working experience in Mental Health Sector/Psychiatric Set-up / Others (must have

experience certifi cateJ : Year _/ M onth of experience (upto 31/10/17)

FulI Signature of the Candidate Declaration I hereby solemnly declare that the information furnished above are based on material records and ^are true to the best of my knowledge and believe. If any information furnished or any ^part of ^{it is found to be incorrect than I understand that my candidature for contractual engagement for the post of Clinical}

Psychologist / Psychologist under DMHP is liable to be cancelled ^{without any further information to me.}

Date & Place: -^{Signature of the ApPlicant}

Bio-Data form for the post of Psychiatric Social Worker _/ Social Worker

/

(To be filled in by the candidate in BLOCK LETTER)

1. Name of the Candidate: Setf
   
   
2. Father's/Guardian's Name: ^attested Passport
   
   
3. Date of birth, ......../..... ./ . .. (DD/MM/YYYY)
   
   

size^{4. Sex} [Male/FemaleJ: photograph

1. Caste ^{& Categories: General/SC /ST /OBC-A/OBC-B/PH}
   
   
2. Address: Permanent Address: PresentAddress:
   
   

P.O.: PIN: District:

1. Mobile Number:
   
   
2. Academic Qualification:
   
   
3. Year of working experience in Mental Health Sector/Psychiatric Set-up / Others [must have experience certificate) :
   
   

Name	University/ Board	Year of Duration	Marks Obtained	Out of Total Marks	%of Marks
Madhyamik or Equiv.
H,S. or Equiv.
Graduation or Equiv.
Post Graduation
M, Phil
Any other qualification

Year_/ M onth of experience (upto 31/10/17)

Full Signature of the Candidate Declaration

I hereby solemnly declare that the information furnished above are based on material records and are true to the best of my knowledge and believe. If any information furnished or any part of it is found to be incorrect than I understand that my candidature for contractual engagement for the post of Psychiatric Social Worker _/ Social Worker under DMHP is liable to be cancelled without any further information to me.

Date & Place: -Signature of the Applicant

_Bio-Data form for the post of Psychiatric Nurse/ Trained ^{General Nurse}

(To be filled in by the candidate in BLOCK LETTER)

-

7. Name of the Candidate: ^Setf

attested

2. Father's/Guardian's Name:

Passport

3. Date of birth, ......../..... I . .. (DD/MM/YYYY)

size

1. Sex [Male/Female): photograph
   
   
2. Caste & Categories: General/SC/ST/OBC-A/0BC-B/PH
   
   
3. Address: PresentAddress:
   
   

Permanent Address:

P.O.: .........,.....

1. Mobile Number:
   
   
2. Academic Qualification:
   
   

Madhyamik or Equiv.

H.S. or Equiv,

Graduation or Equiv.

Any other qualification

_{09. Year of working experience in Mental} Health Sector/ Others _[must fgYgjllg,ence certificate):

Year/ Mo nth of exP erience (upto 31/10/17)

10.

Full Signature of the Candidate Declaration _{I hereby solemnly declare that the information lurnished above are based ^{on material records and are} true to the best of my knowledge and believe. If any information furnished or any ^{part of it is found to be incorrect than I understand that my candidature for contractual engagement for the post of Psychiatric Social Worker / Social Worker under DMHP is liable to be cancelled without any further information to me'}}

Signature of the APPlicant

Date & Place:

Bio-Data form for the post of Community Nurse (Case Manager)

_[To be filled in by the candidate in BLOCK LETTER)

1. Name of the Candidate: Self-attested
   
   
2. Father's/Guardian's Name: ^Passport size
   
   
3. Date of birth, ......../..... . _/ .. . ..(DD/MM/YYYY)
   
   

photograph

1. ^Sex [Male/Female):
   
   
2. Caste & Categories: General/SC/ST/OBC-A _/OBC-B/PH
   
   
3. Address: Permanent Address: Present Address:
   
   

P.0.:

PIN:

District:

1. Mobile Number:
   
   
2. Academic Qualification:
   
   

Madhyamik or Equiv.

H.S. or Equiv.

Graduation or Equiv.

Any other qualification

09. Year of working experience in Mental Health Sector/ Others (must have experience certificateJ:

Year_/M onth of exp erien ce (upto s1/10/17)

Full Signature of the Candidate Declaration

I hereby solemnly declare that the information f,urnished above are based on material records and are true to the best of my knowledge and believe. If any information furnished or any part of it is found to be incorrect than I understand that my candidature for contractual engagement for the post of Psychiatric

Social Worker _/ Social Worker under DMHP is liable to be cancelled without any further information to me.

Date & Place: Signature of the Applicant

Bio-Data form for the post of Case Registry Assistant

(To be filled in by the candidate in BLOCK LETTER)

Setf

1. Name of the Candidate: attested
   
   
2. Father's/Guardian's Name:
   
   

Passport

03. Date of birth: .. ../ ^{. ./} IDD/MM/YYYY)

size

1. ^Sex [Male/Female): photograph
   
   
2. Caste & Categories: General/SC/ST/OBC-A/0BC-B/PH
   
   
3. Address: PermanentAddress: Present Address:
   
   

PIN: District:

07. Mobile Number:
08. Academic Qualification: Name University/ Board	Year of Duration	Marks Obtained	Out ofTotal Marks	%of Marks	l-l
Madhyamik or
Equiv.					i
H.S. or Equiv.					I i

09. Computer Course:

Course Name Institution/ Duration Marks/Grade Obtained %of^,f1 Mark:

Organization Name ^{rks I}

--l

_l

FuIl Signature of the Candidate Declaration I hereby solemnly declare that the information furnished above are based ^{on material records and ar,}true to the best of my knowledge and believe. If any information furnished or any ^part of it ^{is f,ound to b,l incorrect than I understand that my candidature for contractual engagement for the post of Psychiatric Social Worker _/ Social Worker under DMHP is liable to be cancelled without any further information to me.}

_{Date & Place: Signature of the Applicant}

Application format for the post of . (Pl. specify) (BAM/ Sahayika under NRC/ Cook under NRC) (To be filled in by the candidate in BLOCK LETTER)

_t

01. Name of the Candidate: ...........

Self-attested

1. Father's/Guardian's Name: Passport
   
   
2. Date of birth: .........../.........../................... (DD/MM/YYYY) size
   
   
3. Sex fMale/Female): ^photograph
   
   
4. Caste & Categories: General/SC /ST /OBC-A/OBC-B/PH
   
   
5. Address: Permanent Address: Present Address:
   
   

PIN: District:

1. Mobile Number:
   
   
2. Academic Qualification: University/
   
   

Name		Board	Year of Duration	Marks Obtained		Out of Total Marks	%o of Marks
Madhyamik or Equiv.
H.S. or Equiv.
Graduation
Other (Plz specify)
09. Computer Course:
Course Name	I n stitutio n / O rg aniz atio n N a me			Duration	Marks/Grade Obtained		%o of Marks

70. Experience: .sL Year/ Month of experience

Name of the Organization Designation Type of work

No (upto 37/70/77)

11. DD

Full Signature of the Candidate Declaration

I solemnly declare that _[A) all statements made in this application are true, complete & correct to the best of my knowledge ; _[B) Original documents will be produced on demand; (C) I understand that the concerned authority reserve the right to reject my candidature upon short listing of the candidates based on qualifications and experiences as desired by the competent authority.

Date & Place: -

FuIl Signature ofthe Candidate