The Christian Medical Association of India

Address to:-
ADMINISTRATIVE MANAGER
Christian Medical Association of India PASSPORT SIZE
Plot 2, A – 3 Local Shopping Centre RECENT
Janakpuri PHOTOGRAPH
New Delhi – 110 058

APPLICATION FOR EMPLOYMENT

Please fill in the form correctly in your own handwriting

1) Post applied for :-Project Manager

2) Full Name :- Pradeep K Panda.
3) Present Address___At:- Plot no:-1028/399 Nayapally, Gadasahi,
Bhubaneswar___751012_________________________________________________________________________________

Email: pradeepbalasore@gmail.com Phone / Cell:_09437245404

4) Permanent Address_At:- Bikash Nagar, Angaragadia, Po/Dist:-Balasore-756001, Orissa

5) Date of Birth:-12th April 1982 6) Place of Birth:-Orissa

7) Single/ Married/ Widow/ Widower:-Single 8) Nationality:-Indian

9) (a) No. of Children and ages__________________________________________NA____________________________________

(b) Any other dependents and their ages__________________No___________________________________________________

_____________________________________________________________________________________________________

10) Father’s/ Husband’s/ Guardian’s Name:-Sarat Chandra Panda. (Father)

11) Father’s/ Husband’s/ Guardian’s Profession:- Retd.Govt.Employee

12) Religion :-Christian 13) Denomination:-Protestant

14) Height :-5ft6inch 15) Weight:-67 kg

16) General condition of health – Excellent/ Good/ Fair : Excellent

17) Have you any physical handicaps – Sight/ Hearing/ Speech/ Limbs_______NO________________________________________

18) Have you had any major illness in the past year (Yes/No)_____________NO__________________________________________

19) Have you had illness in the past three years where you lost more than 15 days? - Yes/No______NO________________________

(if yes, please give particulars)

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________
Recent Medical certificate be attached

20) Languages know (a) Speak, Read, Writ:-English, Hindi, Oriya

(b) Speak only:-Bengali

21) List your education and professional qualifications:-

Name & Address of Period of Study Degree Diploma Certificate Date of completion
Institution etc.obtained
From To
2009 2011 MBA/MPSM(HealthCare &
IISWBM, Kolkata Hospital) 2011

K.M. Institute of 2003 2007

Pharmaceutical B.Pharmacy 2007
Sciences
1999 2001 10+2 2001
F.M.College
1999 10th 1999
Zilla School

Certified copy of degree, diplomas etc. to be enclosed

22) Registration No.:- (Registered with Pharmacy Council of India under section 31(a) & 32(b) bearing certificate number-
19909
23) State Registration Authority:-Pharmacy Council of India,Orissa

24) Previous experience and service record

Name & Address of Post held Period of employment Reason for leaving
Employer
From To
Pharmacy 6th April 12th July 2009
Sparsh Hospital & manager 2007 Higher Study
Critical care Pvt.Ltd.
Sahid
Nagar,Bhubaneswar

25) Present or last salary drawn (basic)________Rs.13,650/-_____________________________________________________________

(a) In scale if any______________________________________________________________________________________

(b) Allowances________________________________________________________________________________________

26) Which position or department did you consider most interesting and why?

Any Health Care management field because I do think I can execute my Knowledge & experience in that field
27) What extra curricular activities did you participate in, if any?:- I am a member of Students& Professionals Fellowship
28) What office or position did you hold in such activities?:- Active Member
29) Where did you spend the greater part of your life upto16 years of age?:-Orissa
30) How long have you lived at the present address:- 4years

31) Do you regularly read any of the following type of magazine?

News:- Times of India, India Today Fiction:- Ahwan(Oriya)

Professional:-CIMS, IDR, Phramacy Choice, IHI Others :-Books related to The Holy Bible

Give particulars ________________________________________________________________________________________

32) What subjects in school or college interested you most? Science related to the same.
_____________________________________________________________________________________________________
33) Have you at present any particular hobbies or recreational interests? Yes/ No

________________________YES_____________________________________________________________________________

34) Reasons for leaving the present job:- I am presently not employed, I have just Completed MBA(Heath Care & Hospital)

35) Please state below what consideration led you to apply for a post in CMAI:-

CMAI’s commitment towards society for its holistic welfare & development.

36) Are you willing to be transferred to any part of India where CMAI offices might be situated?

Yes/ No. If not, give reasons

YES
_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

37) Are you involved in any Christian activities or organisations e.g., UESI, YFC, Sunday School, etc.

Yes/ No. If yes, state particulars

YES, I am an active participant of Youth Fellowship of New Creation Chruch.
_____________________________________________________________________________________________________

38) Have you any liabilities or debts – Yes/ No - If yes, give particulars

______________________________NO_______________________________________________________________________

_____________________________________________________________________________________________________

39) Are you at present bonded or under contract to any institution or government?

____________________________________NO_________________________________________________________________

40) If you are called for an interview, would you be able to come at your own expense? Yes/ No___________YES________________

41) How soon could you join if selected?__________________15 days_____________________________________________________

42) Duration of appointment desired:- As CMAI decide.

43) Reference: Please give their full address/ phone /Email address

Rev.Dr.P.Niranjan James, ICHTHUS HOUSE,Cuttack-1,mob:-0943764737,E-mail:-dr.niranjan_james@rediffmail.com

(a) A professor or Senior Officer to whom you have been responsible within the past 12 months.

Dr. sanghamitra Sen, Co-Ordinator, IISWBM,Kolkata

(b) Your present pastor or spiritual leader

Ps.Shadrak Kumar Das. Mob:- 09338047307 ;Mail id:- newcreation_bls@yahoo.co.in

(c) Someone other than a relation who has know you during the past five years:

Mr. Priyabrata Mohapatra

CEO, Konark Health Care Pvt.Ltd
Jaydev Vihar
Bhubaneswar
Orissa. Mob no:- 09437014753 ; Mail id:- priyabrat753@gmail.com
44) Any further information about yourself that you would like to give in support of your application

I have considerable knowledge in Herbal Medicines & Ayurvedic System of medicines. I am well versed with computer
application & Cif-tech programme. Excellent communication, interpersonal and relationship management skills are my
forte

BASIC SALARY –

DA –

HRA –

CCA –

TRANSPORT ALLOWANCE –

MEDICAL REIMBURSEMENT (ANNUAL) –

HOSPITALIZATION (ANNUAL) –

LEAVE TRAVEL ALLOWANCE –

PF CONTRIBUTION OF EMPLOYER –

CHILDREN EDUCATION ALLOWANCE –

ANY OTHER ALLOWANCES –

(PLEASE MENTION SEPARETLY)

TOTAL MONTHLY PRESENT SALARY –

I HEREBY CERTIFY THAT ALL THE FORGOING INFORMATION IS TRUE

Date :11/2/2011

Place:-Bhubaneswar
Pradeep Kumar panda
Applicant’s Signature

FOR USE IN THE OFFICE ONLY

(Not to be filled the applicant)

1) Application received on _________________________________________________________________________________

2) Application form sent on_________________________________________________________________________________

3) Application form received back on_________________________________________________________________________

4) References called for on_________________________________________________________________________________

5) Reference received on___________________________________________________________________________________

6) Application considered by________________________________________________________________________________

On________________________________________________________________________________

7) Interview on___________________________________________________________________________________________

8) Result of interview______________________________________________________________________________________

9) Joining Date, if any_____________________________________________________________________________________

10) Any other remarks______________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________