ONLINE APPLICATION FORM FOR
STATE ASPIRATIONAL DISTRICTS COORDINATOR for an International Developement Agency

Position Code: SADC-HLT-AS State(s) in Which the Vacancies Exist: Assam

1. Personal Details:

Applicant's Name:
Father/Husband's Name: Date of Birth:
Gender: 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 the Degree/Diploma
Specialization & Principal Subjects
Name of University/ Institute (City)
Passing Year
Marks (in %)

4. Employment Details. (Please start with current/ most recent experience. If you have worked in more than one area/ post within the same organization, please enter details of the same separately):

# Name of Organisation Designation/ Title Key Responsibilities From To Location (City, State)
1.

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 accordingly urge you to carefully fill your response and provide adequate details.):

# Name of Organisation Details of Job Responsibilities, Tasks, Accomplishments, etc. to Demonstrate Specialisation Duration of Experience (in months) Location (City, State)
 
1. Experience in project management at district and state levels on MCH program with focus on Reproductive, Maternal, Neonatal, Child Health. (Please fill details of your experience in the row below):
 
2. Experience in quality implementation of high impact evidence-based interventions under RMNCH+A . (Please fill details of your experience in the row below):
 
3. Experience in providing high-end technical as well as supportive supervision support to NHM and/ or key government flagship health interventions and coordinating with other related line departments . (Please fill details of your experience in the row below):
 
4. Experience in policy recommendations to address gaps aimed at ensuring preparedness of facility-based health care systems. (Please fill details of your experience in the row below):
 
5. Experience in conducting training/ capacity building workshops for Program Managers for effective Program Management. (Please fill details of your experience in the row below):

6. Details of Present & Expected Remuneration (in Rs.). (Please use this section to report your present gross remuneration and to provide details of expected remuneration for the position that you are applying for):

1. Present Remuneration:
a. Annual Salary/ Consultancy Fees: b. Other Allowances, if any. (Expressed annually, excluding components already included in a.): c. Gross Annual Salary and Allowances/ Consultancy Fees:
 
2. Expected Remuneration. (You will be engaged on a consultancy contract and expected to travel from time to time, as a part of your job responsibilities. Please use this section to indicate expected Professional Fees, and Daily Subsistence Allowance for Field Travel not requiring/ requiring Night Halt):
a. Monthly Professional Fees b. Daily Subsistence Allowance for Field Travel Outside Duty Station Not Requiring Night Halt (covering meals and incidental expenses)* c. Daily Subsistence Allowance for Field Travel Outside Duty Station Requiring Night Halt (covering meals, budget hotel stay and incidental expenses) *
 
( Notes:
(1) Vehicle support shall be provided by the company for travel outside duty station and this cost should not be included
(2) Cost of local travel within duty station shall be borne by the applicant
(3) Candidates are expected to have their own laptops and be internet connected. These items shall not be provided, nor their cost reimbursed.)

7. Computer Skills:

Application
(1) Knowledge of Windows Operating System & Internet:
(2) Proficiency in use of MS-Office
a. Excel
b. Word
c. Powerpoint

8. Language Proficiency:

Language Read Write Speak
Hindi
English
Assamese

9. Location Preferences: in Assam

Preference 1:
Confirm Ability to Travel as per Job Requirement. (Please refer to Vacancy Announcement): Joining Time (in days):

10. Referees. (Please list three persons to whom you have reported professionally in the recent past, whom we can immediately approach for a reference. Please note that this process shall only be executed with candidates who are considered suitable post final interview stage.):

# Name Address Email Phone Organization Designation Your Professional Relationship with the 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.