BABA FARID UNIVERSITY OF HEALTH SCIENCES, FARIDKOT Side - 1

Document Verification Form

(Candidate shall fill the form separately for each post applied
for)
Recruitment of various posts under State Health Agency, Punjab Health System Corporation, Govt. of Punjab.
1. Post Applied Data Entry Operator Cum-Clark
2. Roll No. Written Test: 550100 Marks Obt. In Written Test: 89
3. Applicant Name: VIJAY KUMAR Male/Female MALE
4. Father’s Name: Sh. MAHAVEER
5. Mother’s Name: Smt. VIDYA DEVI
6. Date of Birth: 02/MAY/1984
7. Age as on (01/01/2019) 34 years 07 months 30 days
8. Applied under Category BC
9. Permanent Address: DANGAR KHERA, TEH- FAZILKA
District FAZILKA State PUNJAB
10. Correspondence Address: DANGER KHERA, TEH-FAZILKA
District FAZILKA State PUNJAB
11. Mobile No. 95923-81505 email address: VKJ.NET@GMAIL.COM
12. Whether Passed Punjabi upto Matric level (Yes/No) YES
13. Residence State i.e Punjab (Yes or No): YES (enclose Residence Certificate)
14. Detail of Education Qualification
Sr. Course/Stream Board/University Marks Obtained Subject studied
No. Obt. Max. %age
1. Matric PUNJAB SCHOOL EDUCATION 278 650 42.76 ALL SUBJECTS(ARTS)
BOARD
2. 10+2 PUNJAB SCHOOL EDUCATION 241 450 53.55 PBC, ENG, HIS, POL,PED
BOARD
Detail of Graduation
3. B.A. PANJAB UNIVERSITY 1187 2400 49.45 PBC, ENG, HIS, POL, CSC
CHANDIGARH

Detail of Post Graduation and Master Degree/Diploma & Higher qualification

4. P.G.D.C.A. P. T. U. JALANDHAR 642 1150 55.85 COMPUTER APPLICATION

5. M.Sc. (IT) P.T.U. JALANDHAR 1468 2450 59.91 -----------------------------------

6. M.C.P. MICROSOFT 905 1000 90 Installing, Configuring, and Administering

15. Whether Medical Degree Passed i.e MBBS (Yes/NO) NO

16. Detail of Experience:
Whether
Name of Total Experience
Sr. no. From To Name of Post Regular/Contract/outso
Organization in Month only
urcing
2. 01/07/2014 06/03/2019 SATYAM COLLEGE Asst. Prof. In Computer- CONTRACT 56
FOR GIRLS Science

17. Detail of Additional Experience Under Insurance Sector:

Nature of Job
Name of Total Experience
Sr. no. From To Name of Post Regular/Contract/outso
Organization in Month only
urcing

I solemnly affirm and undertake that the above statement of mine is true to the best of my knowledge and belief and that
nothing has been concealed herein.

Thumb Date Candidates Signature

Impression
(Left in case of male/Right in case of female) (PTO)
Candidate must attach following self attested Side - 2
documents:
 1. Printout of online registration form
2. Admit card of written test
3. Matriculation certificate
4. Matric level Punjabi Passed
certificate 5. 10+2 DMC
6. Detail Marks cards of Graduation/Degree
7. Detail Marks card of Post Graduation Degree/PG Diploma
8. Detail Marks card of Master Degree
9. Experience Certificate
10. Residence Certificate
11. Category Certificate

For Office Use Only

(TO BE CHECKED BY THE DOCUMENT VERIFICATION COMMITTEE)
Tick if document
Document to be checked Signature
Verified

Print out online registration form

Admit card of written test

Matriculation Certificate for Date of Birth

Certificate in regard to Punjabi upto Matriculation level or equivalent

exam

10+2 DMC

Graduation DMC/Degree

Medical Degree i.e MBBS

Post Graduation /PG Diploma degree certificate

Master Degree

Experience certificate from competent authority

Additional. Experience under Insurance Sector from Competent

authority
Any other requisite document

Experience as per certificate attached (Months)

Remarks:
 To be verified by Welfare officer/Nominee
category certificate Eligible/Not Eligible Signature Remarks

SC/BC certificate

To be verified by Sanik Welfare officer/Nominee

category certificate Eligible/Not Eligible Signature Remarks

Ex serviceman category certificate

MEMBER MEMBER MEMBER MEMBER
MEMBER

CHAIRPERSON