7/17/2015

FORM

MINISTRY OF DEFENCE, GOVT. OF INDIA

GUN & SHELL FA CTORY, COSSIPORE, KOL - 2
A PPLICA TION FOR DIRECT RECRUITMENT

A PPLICA TION FORM NO : 1074200030

NA ME OF THE POST : MEDIC AL ASSISTANT

1. C ANDIDATE\'S NAME

PR AKR ITI BISW AS

2. FATHER \'S NAME

NIR ANJAN BISW AS

3. DATE O F BIR TH

03-02-1994

4. GENDER

FEMALE

5 C ATEGO R Y : SC

6. R e ligion: HINDU

7. SUB - C ATEGO R Y

NIL

8. IDENTIFIC ATIO N MAR KS

MAR KS O N LEG

AFFIX
HERE
SAME
PHOTO AS
UPLOADED
(PASSPORT
SIZED)

9. CORRESPONDENCE DETA ILS

POSTA L A DDRESS

MOBILE NO

EMA IL ID

BAR UIPUR GO LPUKUR KAMALENDU

7059794966
R AIC HAUDHUR Y R O AD NEAR TELEPHO NE
EXC HANGE SO UTH TW ENTYFO UR PGS, SO UTH
TW ENTYFO UR PGS, PIN: 700144

10. FEES DEPOSITED : NO

Examination Board/University

biswasprak riti6@gm ail.com

11. PA YMENT TRA NSA CTION NO :

12. MEDIUM OF EXA M : ENGLISH
N/A
13. EDUCA TIONA L QUA LIFICA TIONS
Year of
Marks
Passing
Obtained

Full
Marks

Subject
Combination

10th
STANDAR D

W ESTBENGAL BO AR D O F SEC O NDAR Y

EDUC ATIO N

2009

337

800

GENER AL

12th
STANDAR D

W ESTBENGAL BO AR D O F HIGHER SEC O NDAR Y

EDUC ATIO N

2011

316

600

AR TS

Course

14. PROFESSIONA L QUA LIFICA TIONS

Institution
Year of
% of Marks /
Passing
Grade

GENER AL NUR SING

MIDW IFER Y

C HAR NO C K SC HO O L O F
NUR SING

2015

58.44

Duration of
Course
3.5YR S

14. EXPERIENCE / PREVIOUS EMPLOYEMENT DETA ILS

NIL

DECLA RA TION
1. I he re by de clare that I have the e sse ntial qualification, as pe r the adve rtise m e nt for the post of MEDIC AL
ASSISTANT .
2. I he re by de clare that all state m e nt in the above application form are corre ct. I unde rstand that I am liable to be
disqualifie d at any stage if the inform ation furnishe d above is found to be incorre ct or incom ple te e ve n afte r I
appe ar in the e x am ination
Date : 17-07-2015

(Signature of Applicant)

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(Le ft hand thum b im pre ssion)

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