GOVERNMENT OF ANDRHA PRADESH DISTRICT HEALTH SOCIETY, YSR DISTRICT NOTIFICATION NO.01/2017 RECRUITMENT OF COUNSELLORS AT ADOLESCENT FRIENDLY HEALTH CLINICS. (YUVA CLINICS) UNDER RKSK PROGRAMME ON CONTRACT BASIS APPLICATION FORM REGISTRATION No. Aan photo frebe ea by Ne fe) st pat staon 7] Name ofthe Candidate | Father's 7 Husband's Name 3 [See a [Date of Birth 3 [Age as on F7-2095 5 aS 3 | Socat Status | Whether Physically Handicapped || Yes 7 No [7] ¥ex please mention category =] RAT OR TWH DETAILS OF SCHOOL EDUCATION: class Year of Passing District in which stadied W Vv wr Wi vir % x EDUCATIONAL QUALIFICATIONS: ‘Qualification Year of Name of the College/University passing Degree in Social Work [Waster Sacial Wark[MARKS OBTAINED IN THE QUALIFYING EXAMINATION. ‘Qualifying Examination | Total Narks | Marks Obtained | € of Narks Obtained Degree in Socal Work ‘aster in Social Work ADDRESS PARTICULARS: NAME Father's 7 Husband's Name House Ne. Sireet Tage 7 Town District Pin ‘bile Ne. FEE DETAILS [Demand Draft No: Date “Amount | Name of the Bank & Branch 700-00" ote: All the candidates should enclose Draft for. 100°00 drawn in Favour ‘of istrict Medical & Health Officer, Kadapa from any Nationalized Bank. 1 smt/tum/Srt ‘certty that above particulars furnished by me are correct to the best of my knowledge. | also agre that in the event of any of the particulars furnished in my application being found to be incorrect or false ata later date my candidature will be cancelled summarily [NAME AND SIGNATURE OF THE CANDIDATE FOR OFFICE USE ONLY Date of Receipt of application : ‘Candidate has submitted all the attested copies of the certificates as per instructions ‘All the particulars submitted bythe individual are verified with respect to the certificates and found correct Name & Signature ofthe assistant Name & Signature of the SupervisorCHECK LIST Received application from Sri/Smt.. for application to the post of on. (0ate) (time). Copies ofthe following certificates ae found. 77] photograph duly pasted on the application Form YesT We '55.C or Equivalent examination Yea 7 Ro 3. | Intermediate or 10-2 examination es NO | Degree To Social Work Warks Nemo Yes Wo | Master in Soctal Work Marks Hem Yes No | Latest Caste cotiicate sued By the Tasitdhar MRO YeaT Wo ‘concerned 7. Seuay certificate Tor the years from 4” class to 10" Class [Yes Wo land In case of Private study residence certificate from the ‘Tashildhar /MRO concerned EPH certificate in respect of candidates Claiming YeaT We reservation under PH Quota 9 | Demand Draft Tor Rs. 1007> in favour of DISTRICT MEDICAL ‘& HEALTH OFFICER, KADAPA. Le Name, designation and signature of official recelvng the application form