National Health Mission | Application Form

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Basic Details

All fields marked * are mandatory

Post Applied For *

Preferred District *

Applicant Name *

Father's Name *

Mother's Name *

Date of Birth *

Gender *

Marital Status *

Mobile No. *

Email Address *

Photograph *

🖼 Click to upload Max 100 KB · JPG/PNG

Signature *

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Upload Signature
Max 50 KB

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Citizenship, Category & Fee

Citizen of India? *

Yes No

Country

Category *

Application Fee

₹600INR

Other Details

PwD / Divyangjan?

Yes No

Ex-Serviceman?

Yes No

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Educational Qualifications

Details	Matric (10th)	Intermediate	Graduation	Other (ANM/GNM/Nursing/CCC/PGDCA)
Board / Univ.
Passing Year
Full Marks
Marks Obtained
Percentage	—	—	—	—

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Address Details

Mailing Address

Address Line 1 *

Post Office *

Pin Code *

District *

State *

Permanent Address Same as mailing

Address Line 1 *

Post Office *

Pin Code *

District *

State *

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Declaration & Undertaking

Read each statement carefully and check to confirm.

Declaration

I hereby declare that I have thoroughly checked all the information entered by me and I accept all its terms and conditions.

I hereby declare that all the entries/statements made in this application are true, complete, and correct to the best of my knowledge and belief.

I hereby declare that I fulfill all the prescribed educational/other eligibility criteria. I am aware that in case any information furnished by me is found to be incorrect/false, my candidature will be canceled by the Commission.

Undertaking

Yes, I hereby undertake that I have seen and verified all the entries/statements are complete and correct to the best of my knowledge and belief, and I will never claim any refund of the fee paid by me for this application. I will abide by all the rules and regulations of the Commission and will not indulge in any malpractice during the examination.

Place *

Date

Security Verification

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Security Code *

Type the code exactly as shown. Code is not case-sensitive.