ONLINE APPLICATION FORM FOR
MEDICAL CONSULTANTS- FIELD LEVEL for WHO-NTEP Technical Support Network

Position Code: MC-FL-WNTSN State(s) and District(s) in Which Vacancies Exist: Multiple States- WNTSN

1. Personal Details:
Applicant's Name:
Father/Husband's Name:		Date of Birth:
Gender:	Select Male Female	Mobile No.:
Email ID:		Alternate Contact No.:

2. Address:
Current City of Residence:		City of Domicile(State):
Correspondence/ Current Address with Pin Code:		Permanent Address with Pin Code

3. Qualification Details:
Name of Degree/Diploma	Specialization & Principal Subjects	Name of University/ Institute (City)	Passing Year	Marks (in %)/ GPA	MCI Registration (Only for Medical Qualifications )
Graduation					Not Applicable Yes No
PG Degree					Not Applicable Yes No
PG Diploma Select Course Type Two-year; Full-time, Onsite Non-Two-year; Full-time, Onsite					Not Applicable Yes No
Other Degrees					Not Applicable Yes No
Other Diplomas/ Certificates					Not Applicable Yes No

5. Areas of Specialisation. (Please note that your response to this part of the application form shall be scored and qualitatively assessed to confirm your suitability for the post. We urge you to carefully fill your response and provide adequate details.):
#	Name of Organisation	Details of Key Job Responsibilities, Duties, Tasks Handled and/or Accomplishments to Demonstrate Relevance of Experience in Requisite Areas	Duration of Experience (in months)	Location (City, State)
1.	Experience in providing technical support to public health programmes with focus on planning, training, quality assurance and monitoring & evaluation:. (Please fill details of your experience in the row below):
2.	Experience of coordination and collaboration with District, State, Regional or Central level government health functionaries in the context of PH program implementation and/or scale-up:. (Please fill details of your experience in the row below):
3.	Experience in supportive supervision for developing the capacity of programme staff at state and district levels:. (Please fill details of your experience in the row below):
4.	Experience of facilitating involvement and integration of NGOs and the private health care sector, including private diagnostic facilities and Medical Colleges, with programme service delivery. (Please fill details of your experience in the row below):

6. Present Salary and Allowances in INR lacs per annum. (Please use this section to report your present gross salary):
a. Annual Salary:		b. Annual Allowances* if any. (Excluding components already included in a.):		c. Gross Annual Salary and Allowances:
*Please exclude travel/ per diems and/or other allowances that comprise reimbursement of expenses incurred by you.

7. Computer Skills:
Application
(1) Proficiency in use of MS Office
a. Excel
b. Word
c. Power Point
(2) Proficiency in use of Statistical Software
a. Epi-info
b. SPSS
c. Other Statistical Software (please provide details and confirm proficiency)

8. Language Proficiency:
Language	Read	Write	Speak

Ability and willingness to travel extensively (50%), based on the needs of the job.	Select Yes No	Joining Time (in days):	Select Immediate 0-10 days 11-20 days 21-30 days 31-45 days More than 60 days

10. Referees. (Please list three supervisors to whom you have reported professionally in the recent past, whom we can immediately contact for reference checking. Please note that reference checking shall only be initiated in case the applicant has been found suitable pursuant to final interview ):
#	Name	Address	Email	Phone	Organization	Designation	Your Professional Relationship With and Year of Reporting to Referee
1.
2.
3.

11. Upload CV:

Certification: I certify that to the best of my knowledge and belief, the details submitted by me correctly describe my qualification, experience and other information, as requested by SAMS.