Application Form for State Program Manager

Application Form for State Program Manager

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

5.Details of Relevant Experience:

Please provide details of your experience of independently managing and implementing a PH program(preferably in reproductive health), in close coordination with seniorstate government healthofficials? Please indicate the size of the team managed?

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

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

1st Preference 2nd Preference

3rd Preference 4th Preference

[Note: Preference is likely to be given to local candidates.However, job postings shall be decided by IDF officials on the basis ofinterview 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