URHI APPLICATION FORM by brokeNCYDE

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									       Urban Reproductive Health (URHI) Application Form
INSTRUCTIONS: Please complete and email this form along with your resume to the email ID designated for each position to
which you apply. In case online submission is not possible, please courier applic ation and resume to; Manford Allianz Consultants,
        th
402B, 4 floor, Regent Plaza, MG Road, Gurgaon- 122002, India. The information provided may be shared with the URHI
consortium partners, which include: Family Health International, Hindustan Latex Family Planning Promotion Trust (HLFPPT), Futures
Group, CARE International and Johns Hopkins University Center for Communication Programs (JHUCCP).
1. POSITION you are applying for:
   Which cities would you be willing to work from (please number in order of preference):
           □Agra □Aligarh □Gorakhpur □Allahabad □Moradabad □Varanasi □Mathura □Lucknow
     Which position(s) are you applying for (please list in order of preference)

        1.______________________________                     2._________________________
     Would you like to be considered for short term consulting work               □Yes □No – only full time posts
2. Name (last name, first name)                      3. Date of birth (day/mo/yr)             4. Place of birth (city, state)

5. Gender      □ Female □ Male                       6. Address

7. Email:                           8. Cell phone               9. Home phone                   Citizenship


10. Names & ages of dependent family members:

11. When can you start a new position?                             Have you previously sought employment with FHI?
    Date: mo:_________ year:________
                                                                   □Yes □No        If yes, when? mo/yr:____________
12. LANGUAGE PROFICIENCY: What is your mother tongue?_____________________________
 Languages known                   READ            WRITE         SPEAK          UNDERSTAND
                             Fluent Not        Fluent Not    Fluent Not    Sufficient Not
                                       fluent         fluent        fluent            sufficient
 Hindi
 English
 Other:

14. Education: Please list starting from your most recent degree, and listing back to earliest degree
 Degree                     Date        Major subjects                 Name of Institution                   Location of
                            mo/yr                                                                            institution




13. Please check if you have any of the following experience:
□ Management experience with family planning / reproductive health or MCH programs
□ Clinical experience in reproductive health and family planning services, obstetrics, gynecology
□ Community outreach and mobilization □ Demand generation and communication experience
□ Training and Capacity Building           □ Urban health or development work
□ Private sector marketing, franchising, branding, or vouchers of family planning or MCH services or supplies
□ Insurance, subsidies, incentives, and financing mechanisms to improve access and utilization of services
□ Monitoring, Evaluation, Research, Data Analysis, and Documentation experience
14. What three words would your colleagues use to best describe you?
 15. EMPLOYMENT HISTORY (if any)
 List your work experience beginning with your most recent or current position.
Title/Position          No.             Employer’s name & city       May we     From                 To      Annual
                        reporting                                    contact?                                Salary
                                                                                mo/yr               mo/yr
                        to you     (Supervisor’s name, email, phone)                                         (last)
                                                                               □Yes
                                                                               □No
                                                                               □Yes
                                                                               □No
                                                                               □Yes
                                                                               □No
                                                                               □Yes
                                                                               □No
 List details and other employment history on your resume

 16. SHORT-TERM CONSULTING HISTORY (if any)
 Please list your consulting experience beginning with your most recent or current position.
CONSULTING SERVICES                     Employer’s name & city        May we Dates                          Days      Daily
PERFORMED                                                                                                             rate
                                                                     contact? From       To
                                 (Supervisor’s name, email, phone)
                                                                                          mo/yr    mo/y

                                                                               □Yes
                                                                               □No
                                                                               □Yes
                                                                               □No
                                                                               □Yes
                                                                               □No
 List details and other consulting history on your resume

17. REFERENCES: List three persons, in addition to supervisors listed above, and not related to you, who are familiar
    with your character and qualifications. May we contact your referees? □ Yes □ No
           FULL NAME                  CONTACT DETAILS (Phone/Mobile number)                     OCCUPATION




18. Do you have any organizational enquiries or court case pending against you?            □ Yes □ No
19. Have you ever been convicted? □ Yes □ No
I certify that the information given by me in this application is true and complete. I understand and agree
that any false information, misrepresentation, or concealment of facts is sufficient ground for my
immediate discharge without recourse or refusal of employment. I understand and agree that all
information furnished in this application may be verified.


Date (day/month/year)                                          Scanned signature or type your name
 Please send a detailed Resume in addition this application form. No other documents are required at this
 time. Short listed candidates will be contacted within one month. Thank you for your interest in URHI.

								
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