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UNION PUBLIC SERVICE COMMISSION
DETAILED APPLICATION FORM [DAF]
COMBINED MEDICAL SERVICES EXAMINATION, 2025
RID. : 12515570376
Name : PRATIK SANJAY AMBHORE
Have you ever changed your name? : NO
Email : Pratikambhore007@[Link]
Mobile : 9075212427
1. Name | PRATIK SANJAY AMBHORE
2. (a) Address for correspondence to which | DANGE NAGAR , NEAR NATURE FRESH
SUPERMARKET
Communication is to be sent |
Post Office: | NANDURA
City: | NANDURA
District: | BULDHANA
State : | MAHARASHTRA
Pin Code : | 443404
(b) Telephone No. (with STD Code) | -
(c) Mobile No. | 9075212427
(c.1) Alternate Mobile No. |
(d) Fax No. |
(e) E-mail address | PRATIKAMBHORE007@[Link]
(f) Permanent Postal Address | DANGE NAGAR , NEAR NATURE FRESH
SUPERMARKET
|
Post Office: | NANDURA
City: | NANDURA
District: | BULDHANA
State : | MAHARASHTRA
Pin Code : | 443404
3. (a) Citizenship : | A CITIZEN OF INDIA(1)
(b) Nationality : | INDIAN
4. Gender : | MALE
5. Marital Status : | UNMARRIED
(If Married, Nationality of spouse) |
6. Mother tongue : | MARATHI
7. (a) Date of Birth | 13-12-1998
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(b) Claimed age relaxation | NO
8. Place of Birth :
If born in India: | YES
Post Office | BHATKULI
City/Town/Village | BHATKULI
District | AMRAVATI
State | MAHARASHTRA
Pincode | 444602
9. (a) Community | OBC (3)
Note 1: No change in the community status already indicated by candidate in his / her application form for
this examination will be allowed by the Commission except in the circumstances mentioned in the
Rules of Combined Medical Services Examination, 2025.
Note 2: In case you are a SC or ST category candidate, upload a scanned copy of certificate in prescribed format
in support of your claim. The certificate must be issued latest by the date of closure of online application
form for Combined Medical Services Examination, 2025.i.e. 11.03.2025
Note 3: In case you are EWS Category candidate, upload a scanned copy of ‘Income and Asset Certificate’ in
prescribed format based on the income for Financial Year 2023-24 (i.e. for the period from 1st April, 2023
to 31st March, 2024) in support of your claim. Certificate based on the income of any other Financial
Year shall not be treated as valid. The Certificate must be issued on/after 01.04.2024 (after the completion
of FY 2023-24) but not later than the closing date of the application for Combined Medical Services
Examination-2025.i.e. 11.03.2025. Such candidates must meet the Income and Asset
criteria issued by the Central Government.
Note 4: In case you are an OBC Category candidate, upload a scanned copy of OBC (Non-Creamy Layer)
certificate in prescribed format based on the income for the Financial Years (FYs) 2023-24, 2022-23
and [Link] Certificate must be issued on/after 01.04.2024 (after the completion of FY 2023-24) but
not later than the closing date of the application for Combined Medical Services
Examination-2025. i.e. 11.03.2025.
Note 5: The I&A Certificate uploaded only will be treated as final and no certificate/documents
after the closing dateof online application of CMSE, 2025 will be accepted. The submission of document(s)
must be done through this online DAF platform only.
(b) Certificate No. |
(c) Date of issue |
(d) Designation of issuing authority |
(e) Full address of issuing authority |
(f) Name of the Caste as mentioned in | KUNBI ()
the Community Certificate and |
Name of the issuing State.
[For SC/ST/OBC Candidates]
(g) State Creamy or Non Creamy Layer | Creamy Layer
(h) If you belong to any of the minority
Communities notified by the Government
(Muslim/Christians/Sikhs/Buddhists/
Zoroastrians[Parsi]/Jains) | NO
(i) If yes, Name of the Minority
community |
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10.1.(a) Whether you are a PwBD/PwD | NO
candidate
(b)(1) Category |
(b).2 Indicate Form Type of the Certificate |
of Disability
(c) Percentage of disability as indicated in |
the Certificate of Disability
(d) Certificate No. |
(e) Date of Issue |
(f) Designation of issuing authority |
(g) Full address of issuing authority |
(h) Are you a PwBD/PwD candidate [as |
per column 10.1.(a)] having physical
limitation to write?(If Yes, upload
scanned copy of the requisite certificate
as per Appendix-V (for PwBD) /
Appendix-VII (for PwD)of the Notice
of CMSE Exam, 2025 dated 19th
February, 2025)
(j)(i) If yes, "Commission's Scribe" or "Own |
Scribe"
(k) Would you require any assistive |
device(s)
(l) Would you require question paper in | NOT APPLICABLE
larger font size?
Note: Larger font is only for PwBD Candidates suffering from Blindness/ Low Vision.
10. 2. Have you ever been recommended as a | NO
(a) PwBD candidate in the examinations
conducted by the UPSC in the past?
(b). If yes, mention name and year of the examination(s) with Roll No.
Name of the Examination Year of the Roll No.
Examination
(c) Whether such recommendation was on | NO
the basis of the Certificate of Disability
NOW UPLOADED by you for the
CMSE, 2025?
(d) After any such recommendation by the | NO
UPSC were you ever found UNFIT/
NOT RECOMMENDED by the Central
Standing Medical Board or any other
Medical Board constituted by the
Government with regard to your
physical disability?
(e) If yes, provide details thereof |
11. (a) Name of Father | SANJAY DEVIDAS AMBHORE
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(a.1) Status | ALIVE
(b) Name of Mother | CHHAYA SANJAY AMBHORE
(b.1) Status | ALIVE
(c) Nationality of Father | INDIAN
(d) Nationality of Mother | INDIAN
(e) Father's Profession: | TEACHING
(f) Mother's Profession: | HOMEMAKER
(g) If Father is in service, post held by him | ASSISTANT TEACHER
(g)(i) if retired indicate the post held
by him at the time of his retirement,
otherwise fill 'NOT APPLICABLE' | NOT APPLICABLE
(h) If Mother is in service, post held by her | HOMEMAKER
(h)(i) if retired indicate the post held
by her at the time of her retirement,
otherwise fill 'NOT APPLICABLE' | NOT APPLICABLE
(i) Annual income of your Father for | Rs.1250000
financial year 2023-2024
(j) Annual income of your Mother for | Rs.0
financial year 2023-2024
(k) State to which your Father originally | MAHARASHTRA
belongs
(l) District to which your Father originally | BULDHANA
belongs
(m) State to which your Mother originally | MAHARASHTRA
belongs
(n) District to which your Mother originally| AMRAVATI
belongs
(o) Father's present postal Address | DANGE NAGAR , NEAR NATURE FRESH
SUPERMARKET
(If deceased give last address) |
Post Office: | NANDURA
City: | NANDURA
District: | BULDHANA
State : | MAHARASHTRA
Pin Code : | 443404
(p) Mother's present postal Address | DANGE NAGAR , NEAR NATURE FRESH
SUPERMARKET
(If deceased give last address) |
Post Office: | NANDURA
City: | NANDURA
District: | BULDHANA
State : | MAHARASHTRA
Pin Code : | 443404
12. What Languages(including Indian Languages) can you read/write or speak ? Give particulars and state the
examination(s) passed, if any, for each :-
Read Only Speak Only Read & Speak Read, Write & Examination(s)
Speak passed
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HINDI 10TH
MARATHI SCHOOL
EXAMINATIONS
13. (a) Do you possess the prescribed Educational
Qualification (Vide rule-6 of the rules of the Examination)?
Please upload a scanned copy of the Certificate
if the answer is "YES" | YES
(b) Certificate No./Enrolment No./Roll No. | 0118190486
(c) Date of issue | 2022-05-18
(d) Designation of issuing authority | CONTROLLER OF EXAMINATIONS
(e) Full address of issuing authority | MUHS NASHIK
Note : If you do not possess the prescribed educational qualification as mentioned in rule-6 of the
examination your candidature is liable to be cancelled. The proof of passing the requisite qualifying
examination should have been issued latest by the closing date of Detailed Application Form of the
COMBINED MEDICAL SERVICE EXAMINATION, 2025
(f)(i) Do you have any basic Educational
Qualification or higher qualification
obtained from a foreign institution? | NO
14.1 Educational Qualifications : Commencing with Matriculation or equivalent examination till Graduation:-
(Please upload scanned copy of all Certificates/Degree)
Examination Class/ Percentage CGPA Year of Subject(s) Name of Name of
Passed Division of Score Out of School/College Board/University
/Grade Marks(%) Passing /Institution
10th or Equivalent NOT AP 10 10 2015 ENGLISH HINDI SMT TULSIBAI R Z CENTRAL BOARD
PLICAB MATHS SCIENCE VIDYANIKETAN OF SECONDARY
LE SOCIALSCIENCE NANDURA EDUCATION
BULDANA DELHI
12th or Equivalent NOT AP 87.84 2017 ENGLISH PHYSICS SHRI SAMARTH MAHARASHTRA
PLICAB CHEMISTRY COLLEGE OF BOARD OF
LE BIOLOGY FRESH SCIENCE AKOLA SECONDARY AND
WATER FISH HIGHER
CULTURE SECONDARY
ENVIRONMENT EDUCATION
EDUCATION PUNE
Stream at Graduation Level :-- MEDICAL
MBBS NOT AP 66 2022 MEDICINE GRANT MAHARASHTRA
PLICAB SURGERY OBGY GOVERNMENT UNIVERSITY OF
LE PEDIATRICS MEDICAL HEALTH
COLLEGE MUMBAI SCIENCES,
NASHIK,
MAHARASHTRA
14.2 Higher Educational Qualifications : Commencing with Post Graduation or equivalent examination :-
Examination Class/ Year of Date of Likely date CGPA Percentag Subject(s) College/Institution Board/
Passed/ Division Passing Joining of Score Out of e University
Appeared/ /Grade Completion of
Appearing Marks(%)
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15. (a) Whether passed written and practical
parts of final MBBS Examination : | YES
(b) Date of written and practical part of
final MBBS Examination : | 18-05-2022
16. (a)Whether completed Rotating
Internship: | YES
(b) Date of completion of compulsory
Rotating Internship : | 23-05-2023
(c) Likely Date of completion of
Internship : | 23-05-2023
16.1 Are you currently a student of
Post Graduation/Diploma
course after MBBS | NO
17 Were you ever employed? : | YES
If yes, Are you in
Government/Public Enterprise | NO
If yes, Date of intimation in writing
to your Head of Office/Department
regarding appearing in Combined
Medical Services Examination 2025 |
Note: The candidates employed in Government/Public Sector Enterprise/Government Autonomous Bodies
must ensure that they have intimated their parent Department before applying for this Examination with
proof of receipt by the Department. If it is found, that the candidates have not done the same, their
candidature is liable to be rejected forthwith without any further notice.
Details of your employments (in chronological order till date)
Designation/Posi Monthly Whether Perman Period Name of Place of Employment
tion remuneration ent/Temporary/ From To employer/ (Address)
(Total) in Rupee Ad-hoc dd-mm- dd-mm- Organisation/
yyyy yyyy Firm/Individual
MEDICAL 75000 OTHERS 2023-10-16 2024-03-14 GOVERNMENT TAKARKHED, NANDURA
OFFICER , BULDANA
17.1 Have you been self-employed?: | NO
18. Please give Particulars at the University/State/National Level in respect of:-
(a)Prizes, Medals, Scholarships etc. |
(b) Sports/N.C.C. etc. |
(c) Position(s) of distinction Leadership held in | HEAD BOY AT SCHOOL
School/College
(d) Other extracurricular activities and interests (Such | LISTENING SONGS, TRAVELLING AND
as hobbies etc.) TREKKING
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19. Your order of preference against the Services/Posts given below,for which you wolud like to be
considered for appointment. Please give your choice for Category first and thereafter
indicate the order of preferences for the services under category-II.
First Preference :- Category 2
Name of Services/Post Order of Preference
1. Assistant Divisional Medical Officers in the Railways 1
2. General Duty Medical Officer in New Delhi Municipal Council 2
3. General Duty Medical Officer [Link] in Municipal Corporation of Delhi 3
Second Preference :- Category 1
Name of Services/Post Order of Preference
1. Medical Officers Grade in General Duty Medical Officers Sub-cadre of Central Health 1
Service
20. Photo-ID Proof | AADHAR CARD (XXXXXXXX2082)
21. Have you ever been debarred by
the UPSC from any of its
Examinations/Selections? | NO
22. Whether you have ever applied for
U.P.S.C. Examination /Recruitment
(Excluding Current Examination): - | NO
23. List of Scanned documents uploaded by the candidate:-
--> Matriculation Certification / School Leaving Certificate as proof of date of birth or any other
certificate/document as prescribed in the rules for the exam.
--> The certificate of graduation or equivalent educational qualifications (including a copy of recognition
letter / equivalence certificate from AIU/UGC, if applicable)
--> The selected Photo ID Proof (viz. Aadhaar Card, Voter Card, PAN Card, Passport, Driving Licence or
any other Photo ID Proof issued by the Central/State Government.)
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DECLARATION BY THE CANDIDATE
I, hereby declare that all statements and entries made in all the columns of this application are true,
complete and correct to the best of my knowledge and belief.
2. That I have read rules of the Examination published in Part I –
Section 1 of the Gazette of India Extraordinary dated 12th February, 2025 and understand that in the
event of any information being found false or incorrect or ineligibility being detected before or
after the examination action can be taken against me by the Commission.
3. That I further declare that I fulfil all the eligibility conditions regarding age limits, educational
qualifications etc. prescribed for admission to the Examination.
4. That I have not withheld any information required as per this Detailed Application Form.
5. I have thoroughly scrutinised the list of scanned documents as enumerated
and uploaded scanned copies of all the documents relevant for me.
6. That I have read the Rules of Examination and the instructions carefully and I hereby undertake to abide
by them.
7. That I have informed my Head of the Office/Department in writing that I have applied for this
examination.
Signature of the Candidate
[Note: Online submission of the DAF by the candidate within prescribed time period is
construed as his/her signed application]
RID :- 12515570376 |
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