B. K. Memorial Hospital, Tezpur
EMPLOYEE INFORMATION FORM
To be completed by the candidate.
Position Applied
Post Applied
Department
Date of Application
Proposed DOJ
1. Personal Information
Full Name (as per Aadhaar/PAN)
Father's Name
Mother's Name
Spouse's Name (if applicable)
Date of Birth
Gender
Select
Male
Female
Other
Marital Status
Select
Single
Married
Divorced
Widowed
Nationality
Religion
Blood Group
Category
General
OBC
SC
ST
EWS
Others
2. Contact Details
Mobile (Aadhaar linked)
Alternate Mobile
Email
Permanent Address
Present Address
Permanent Address PIN
Present Address PIN
3. Identity Details (Photocopy to be provided)
Document
Document Number
Aadhaar
PAN
Voter ID
Driving Licence
Passport
4. Educational Qualifications (Photocopy to be provided)
Qualification
Board/University
Year
% / CGPA
HSLC
Higher Secondary
Diploma
Graduation
Post Graduation
Others
5. Professional Registration (if applicable) (Photocopy to be provided)
Registration
Number
Valid Till
Medical
Nursing
Pharmacy
Other
6. Work Experience
Employer
Designation
Duration
Reason for Leaving
Total Experience:
Years
Months
7. References
Reference 1 Name
Reference 1 Mobile
Reference 2 Name
Reference 2 Mobile
8. Emergency Contact
Name
Relationship
Mobile
9. Bank Details
Bank Name
Branch
Account No.
IFSC
10. EPFO & ESIC
UAN
ESIC No.
Previous Member
Yes
No
11. Medical Information
Chronic Illness
Allergies
Physical Disability (if any)
12. Declaration
I hereby declare that the information provided above is true and correct to the best of my knowledge. I understand that any false information may lead to cancellation of my candidature or termination of employment. I authorise the organisation to verify the information provided by me.
Candidate Signature
Date
Place
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