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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