Application Form for Clinical Specialist, Training and Provider Support (Nurse)

Application Form for Clinical Specialist, Training And Provider Support (Nurse)

1. Biographical Information:

Applicant’s Name: / Mr./ Ms. / First Name: / Middle Name: / Last Name:
Date of Birth: / Date / Month / Year / Father’s Name:
Email ID: / Mobile No.:
Landline Phone No.(including STD Code):
Gender: / Marital Status:

2. Address:

Current Location (City, State):
Correspondence/ Current Address with Pin Code: (Please provide below) / Permanent Address with Pin Code:
(Please provide below)

3. Educational Details:

Examination
Passed / Name of the Course / Specialization & Principal Subjects / University/ Institute / Passing
Year / Marks (in %)
(1) Graduation:
(2) Post Graduation:
(3) Other Degree/ Diploma:

4. Work Experience [Please start with current/ most recent experience. If you have worked in more than one post within the same organization, please provide separate details for each]:

Name of Organization / Designation/ Title along with Duration [e.g. IT Officer, June-2007 to June-2008] / Key Areas of Experience & Job Responsibilities
[Mention atleast 3 key Job responsibilities] / Experience
(in months)

5. Details of Relevant Experience:

Please share details of your experience of working on reproductive health and family planning programs, especially relating to comprehensive Intra-Uterine Contraceptive Device (IUCD), including Interval IUCD, Postpartum IUCD and Post Abortion IUCD.

Details of Experience Possessed: [Maximum Characters allowed: 500]

6. Location Preferences (Please indicate names of cities for your first two preferred work locations. Please refer to Annexure I on Page 4 for location details):

1st Preference 2nd Preference

[Note: Preference is likely to be given to local candidates. However, job postings shall be decided by IDF officials on the basis of interview outcomes, vacancies at different locations and program priorities]

Certification: I, the undersigned certify that the above mentioned details correctly describe my qualifications, experience and personal status to the best of my knowledge and belief.

Date:

Place:Applicant's signature

ANNEXURE-I

Location Details (Position wise)
Sl. No. / Position / Location
1 / Executive - Program*** / Assam
Chattisgarh
Odisha
Karnataka
Madhya Pradesh
Jharkhand
2 / Executive - Admin / Raipur (Chattisgarh)
Bhubaneswar (Odisha)
Bengaluru (Karnataka)
3 / Asst. Manager - Program*** / Assam
Chattisgarh
Odisha
Karnataka
Bihar
Madhya Pradesh
Jharkhand
4 / Manager - Program / Kolkata (West Bengal)
Bhopal (Madhya Pradesh)
5 / State Program Manager / Bhubaneswar (Odisha)
Bengaluru (Karnataka)
Bhopal (Madhya Pradesh)
Ranchi (Jharkhand)
6 / Director - Health Systems / New Delhi, Delhi
7 / Clinical Specialist - Training & Provider Support (Doctor)*** / Madhya Pradesh
Jharkhand
8 / Clinical Specialist - Training & Provider Support (Nurse)*** / Madhya Pradesh
Jharkhand
9 / Project Director / New Delhi, Delhi
[Please Note: *** The positions will be based at district headquarters across the state]

Application Format (IDF) Strategic Alliance Management Services Pvt. Ltd Page 1 of 4