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Application Form

Refrence No.: N/ACTREC-ADVT-A-2-2022/03069

Advt No.: ACTREC/ADVT-A-2/2022

Name of the Post: NURSE ‘A’ FEMALE

Personal Information

Title	Ms.	Surname	Pol	First Name	Rutuja
Middle Name	Subhash	Date of Birth	03/05/1999 03/05/1999 00:00:00	Age(Year/Month/Days)
Gender	Female	Nationality	Indian	Marital Status	UNMARRIED
Spouse Name		Address	B4 / B / 101, Gitanjali Housing Society, Sector-10, Near Gurudwara, Kalamboli	Pincode	410218
Country	INDIA	State:	Maharashtra	City:	Navi Mumbai
Is Permanent Address same as Present Address
Belong to	Open	Telephone No.	9967195494	Mobile No.	8850186954
Email Id	mayur.pol99@gmail.com	Skype ID		Are you presently working in TMC/DAE unit	No

Educational Qualification (Starting from latest Degree.)

Sr No.	Degree Name	Subject Name	Institue Name	University Name	Result	Passing Month	Passing Year	Percentage/GPA	Course Type	Course Duration	Certificate enclosed
1	Basic or Post Basic B. S.C. (Nursing)		MGM New Bombay College Of Nursing, Kamothe	MGM Institute of Health Science	Pass	9	2020	61.00 /	Full Time	4 Years,0 Months	Yes View Certificate File

Experience (Starting from current Experience.)

PAST AND PRESENT EXPERIENCE/Teaching work experience [for present experience (if any) TO DATE of experience should be current date.] Experience certificate indicating the date of joining and relieving. Current Employment: Appointment letter,Last Pay Slip, Identity Card. Documentary evidence is necessary.

Sr No.	Post	Experience Type	Organization	Job Type	Gross Salary(Monthl In INR)	From Date	To Date	Years/Months/Days	Application is in service	Nature of Work	Certificate Enclosed
1	Staff Nurse	Non Teaching	MGM Medical College and Hospital	Full Time	21638.00	01/04/2021	06/03/2022	0/11/5	Private	Full Time	Yes View Certificate File
2	Trainee Nurse	Non Teaching	MGM Medical College and Hospital	Full Time	15000.00	14/12/2020	31/03/2021	0/3/17	Private	Full time	Yes View Certificate File

Total Working Experience:
Total Year		Total Month		Total Day

Gap In Experience Information

It is Mandatory to submit Documents Related to Professional Experience.If not, Experience will not be considered. If there is a gap (more than 1 month) between experience, then reason for the same has to be mentioned below.

Whether Gap in Professional Experience: No

Medical Council Information

Medical Council Place: Maharashtra

Registration Number: II-31463

Referee Details : (First and Second referee should be Mandatory)

	First referee*	Second referee*	Third referee
Name:	Esther C Leela	Smitha Kuriakose	Manasi Patil
Designation:	Ward Incharge	Senior Staff Nurse	Staff Nurse
Address:	MGM Hospital, Kamothe	MGM Hospital, Kamothe	MGM Hospital, Kamothe
Tel. No.:	9819588729	8879078488	7719065790
Fax No.:
Email:	nancynixu@gmail.com	smithamerinkuriakose@gmail.com	manasidpatil79@gmail.com

Other Information

Proof of Date of Birth

Proof of Date of Birth:

Whether SC/ST: No

SC/ST proof:

Whether EWS/SBC/NT: No

EWS/SBC/NT proof:

Whether OBC/Non-Creamy Layer Certificate: No

OBC/Non-Creamy Layer Certificate:

Whether Person with disability (PWD): No

Percentage of Disability: 0

Person with disability PWD proof:

Whether Applicant is in service of Govt. / Semi.Govt. / PSU: No

Whether N.O.C is obtained: No

No objection certificate:

Whether Application is routed through proper channel: No

Whether applicant is Ex-serviceman: No

Proof of your Ex-serviceman:

Whether Proof for Current Employment Attached: Yes

Proof Type: Appointment Letter

Proof for Current Employment:

Notice required for joining the post (MENTION NO. OF DAYS E.G. 10 DAYS, 1 MONTH ETC.): 1 MONTH

Particular's about Pension / Provident Fund etc.:

Describe (in 150 words) your most notable contribution in Service, Teaching or Research: working full time During Covid

Any other information you wish to add:

I hereby declare that all the information and particulars given by me in this application are true and correct to the best of my knowledge. I am aware that if any of the above statements are found to be incorrect or false or may material information or particulars of relevance have been misstated, suppressed or omitted, my application will be rejected and if such discrepancies come to light after I am selected, my appointment will be terminated.

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16/05/2025