F:\notice_therapist_10_12_12.docx

APPLICATION FOR EMPANELMENT OF THERAPIST AT SSM, BARDHAMAN

Name of the applicant (in Block Letter) :-

Self a ested

Father’s / Husband’s name:-

Passport Photo

Address

Gender (M / F) :-

Village / Town :-

Police station :- Post Office :-

District :-

Pin No :-

Contact number :-

Date of Birth (DD/MM/YYYY) …..…/ …..…/ …..…

email address:-

Educational Qualification (Enclose self attested certificates)

Name of Board/Council / University Year of

Examina on Passed

% of Marks obtained

Qualification as Therapist (Enclose self attested certificates)

Experience (if any) (Enclose self attested certificates)

Name of the organization(s) Year / Month of Experience Total experience

I do hereby declare that all statesmen made in this application are true and correct. In the event of any information being found false, my candidature is liable to be cancelled, even on empanelment.

Signature of the applicant

Examina on Passed

Name of Board/Council / University Year of

Examina on Passed

% of Marks obtained

Examina on Passed

APPLICATION

APPLICATION FOR EXISTING THERAPIST AT SSM, BARDHAMAN(WRITE IN CAPITAL LETTER IN BLACK/BLUE PEN ONLY)

1. Name :

2. Contact number :

3. Email address (WRITE IN CAPITAL LETTER):

4. Name of CLRC where attached as Resource Person (Physiotherapist) from past years

a. In the year 2013-14 : (if applicable)

b. in the year 2014-15 :

5. For the financial year 2015-16 I want to work as Resource Person (Physiotherapist)

(Preference wise):

1) CLRC

2) CLRC

3) CLRC

Declaration:

I want to attach with SSM, Bardhaman as Resource Person (Physiotherapist) for 2015-16

financial year. I declare that I also interested to work as Resource Person

(Physiotherapist) at any CLRC of Burdwan district if not even placed at any one of my

preferred CLRC.

Signature of Applicant