ONLINE APPLICATION REGISTRATION FOR ASSISTANT MEDICAL

OFFICER (SIDDHA) 2025

USER ID MRBAMOS003457
POST APPLYING FOR ASSISTANT MEDICAL OFFICER (SIDDHA)

PERSONAL DETAILS
NAME THARA PARVEEN J
NATIONALITY INDIAN
ARE YOU AN EX-SERVICEMEN NO
DO YOU HAVE COMMUNITY CERTIFICATE ISSUED BY YES
TAMILNADU GOVT.?
COMMUNITY BCM
SUB CASTE LABBAI
ISSUING AUTHORITY OF COMMUNITY CERTIFICATE TAHSILDAR
COMMUNITY CERTIFICATE NO 13631/05
COMMUNITY CERTIFICATE PLACE OF ISSUE DHARMAPURI
COMMUNITY CERTIFICATE ISSUING DATE 26-SEP-2005
ARE YOU DIFFERENTLY ABLED? NO
DATE OF BIRTH (AS PER SSLC MARK SHEET) 16-JUL-1980
AGE AS ON 01.07.2025 44 YEARS 11 MONTHS 15 DAYS
EMAIL ID THARA16PBV2@[Link]
MOBILE NO 8610662264
WOULD YOU LIKE TO GIVE FATHER AND MOTHER GUARDIAN
NAME OR GUARDIAN NAME
GUARDIAN'S NAME SYED BURHANUDDIN AHMED S N
ARE YOU MARRIED YES
NAME OF SPOUSE SYED BURHANUDDIN AHMED S N
NATIVITY CHENNAI - TAMIL NADU

GENDER FEMALE
RELIGION MUSLIM
ARE YOU ALREADY IN GOVERNMENT SERVICE? NO

PHOTO ID PROOF DETAILS

PHOTO ID PROOF NO. TIK0336636

PERMANENT ADDRESS
ADDRESS 25,BROOKDALE APARTMENT,4 FLOOR,NANDANAM EXTENSION,14
STREET,NANDANAM,CHENNAI,600035
STATE TAMIL NADU
DISTRICT CHENNAI
CITY / VILLAGE CHENNAI
PINCODE 600035

04-03-2025 10:30:27 1
 CORRESPONDENCE ADDRESS
ADDRESS 25,BROOKDALE APARTMENT,4 FLOOR,NANDANAM EXTENSION,14
STREET,NANDANAM,CHENNAI,600035
STATE TAMIL NADU
DISTRICT CHENNAI
CITY / VILLAGE CHENNAI
PINCODE 600035

MOTHER TONGUE
MOTHER TONGUE URDU

EDUCATIONAL QUALIFICATION
EXAMINATION NAME OF THE BOARD OTHER BOARD MONTH/YEAR OF MEDIUM OF HAVE YOU STUDIED
PASSING INSTRUCTION TAMIL AS ONE OF THE
LANGUAGE (PART-1)
10TH / SSLC TAMIL NADU STATE - MARCH 1995 ENGLISH YES
BOARD
12TH / HSC TAMIL NADU STATE - MARCH 1997 ENGLISH YES
BOARD

EXAMINAT DEGREE OTHER NAME MONTH/ RECOGNI MEDIUM ARE YOU DATE OF TAMIL REGISTR REGISTR
ION NAME EQUIVAL OF YEAR OF ZED OF A REGISTR NADU ATION ATION
ENT UNIVERS PASSING UNIVERS INSTRU REGISTE ATION MEDICAL CARD VALID
DEGREE ITY ITY YES/ CTION RED COUNCIL TYPE UPTO
NO PRACTIT NUMBER
IONER
UNDER B.S.M.S - THE OCTOBE YES TAMIL YES 01- 2459 PERMAN -
GRADUATE TAMIL R 2002 SEP-200 ENT
NADU 3 VALID
DR.M.G.R CARD
.
MEDICAL

UNIVERS
ITY

EXAMINATION DO YOU HAVE DEGREE SPECIALIZATION MONTH & YEAR OF PASSING

EXAMINATION ARE YOU ELIGIBLE TO AVAIL HAVE YOU STUDIED IN TAMIL HAVE YOU STUDIED YOUR UG IN
PSTM PREFERENCE? MEDIUM FROM 1ST STANDARD TAMIL MEDIUM?
TO 12TH STANDARD?
PSTM NO - -

UPLOAD DOCUMENTS
DOCUMENT NAME FILE NAME
COMMUNITY CERTIFICATE _.PDF
MEDICAL COUNCIL REGISTRATION CERTIFICATE _.PDF
SSLC CERTIFICATE _.PDF
HSC CERTIFICATE _.PDF
UG DEGREE CERTIFICATE _.PDF
PG DEGREE CERTIFICATE _.PDF

04-03-2025 10:30:27 2
 DECLARATION
I HEREBY DECLARE THAT ALL THE PARTICULARS FURNISHED IN THIS APPLICATION ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF
MY KNOWLEDGE AND BELIEVE. IN THE EVENT OF ANY INFORMATION BEING FOUND FALSE OR INCORRECT OR INELIGIBILITY BEING DETECTED
BEFORE OR AFTER THE SELECTION, ACTION CAN BE TAKEN AGAINST ME BY THE MRB.
I HEREBY DECLARE THAT I WILL NOT BE A PARTY TO ANY KIND OF CANVASSING ON MY BEHALF.
I FURTHER DECLARE THAT I FULFIL ALL THE ELIGIBILITY CONDITIONS PRESCRIBED FOR ADMISSION TO THIS POST.
I HAVE INFORMED MY EMPLOYER IN WRITING THAT I AM APPLYING FOR THIS POST AND FURNISH THE NOC FOR THIS PURPOSE (IF
APPLICABLE).
I HAVE GONE THROUGH THE INSTRUCTIONS ETC. TO CANDIDATES AND THE BOARDS NOTIFICATION FOR THIS RECRUITMENT, BEFORE
FILLING UP THE APPLICATION FORM AND I AM ELIGIBLE TO APPLY FOR THIS POST.
I DECLARE THAT I POSSESS THE MEDICAL STANDARDS PRESCRIBED FOR THE POST(S) WHICH I AM NOW APPLYING.
I CERTIFY THAT I HAVE NOT BEEN DEBARRED / DISQUALIFIED BY THE BOARD OR ANY OTHER RECRUITING AGENCY.
I AM NOT A DISMISSED GOVERNMENT EMPLOYEE.
THERE IS NO CRIMINAL CASE FILED AGAINST ME IN THE POLICE STATION / COURT.
THERE IS NO VIGILANCE CASE FILED AGAINST ME.
I HEREBY DECLARE THAT MY CHARACTER / ANTECEDENTS ARE SUITABLE FOR APPOINTMENT TO THIS POST.
I DECLARE THAT I DO NOT HAVE MORE THAN ONE LIVING SPOUSE.

SUBMITTED DATE : 03-MAR-2025 (SIGNATURE OF THE CANDIDATE)

04-03-2025 10:30:27 3