Application for the enlistment of Visiting Consultant with Health & Family Welfare Department, Government of West Bengal (Ref Advertisement No:- DHS/Singly/S-71/2016 dated 08.12.2016) To The Director of Health Services & e.o. Secretary Health & Family Welfare Department Government of West Bengal 1. Applicant’s Name:- Dr. 2. MCI Registration No:- 3. Category:- MBBS Only/Jr. Consultant/Sr. Consultant Date of Birth:- (DD-MM- 4. YY) Paste Passport 5. Gender:- size recent Father’s/ Husband’s 6. photograph with Name:- signature 7. Permanent Address:- 7.a. House: 7.b. Street:- 7.c. Village / Town:- 7.d. PIN CODE:- 7.e. Police Station:- 8. Address for communication (If different from above):- 8.a. House: 8.b. Street:- 8.c. Village / Town:- 8.d. PIN CODE:- 8.e. Police Station:- 9. Mobile No:- 10. e-Mail:- 11. MBBS Qualification:- Board/ University Year of Passing Specialization:- (Optional) If required Candidate may attach additional sheet. Specialist in Board/ University Year of Passing 12. Choice of Consultation:- Preferred Day for service 13. (Select maximum 3 days a week and Maximum 6 hours per day) Day1 Hour1 Day2 Hour2 Day3 Hour3 14. Choice of Hospitals # (up to three preferences) District 14.a. 14.b. 14.c. 15. Present Working Status 15.a. Name of Hospital/ Nursing Home/ Chamber:- 15.b. Address:- DECLARATION I declare that the information furnished above is based on material records and are true to the best of my knowledge and belief. I also understand that if any information furnished is found to be materially incorrect or incomplete, I will be liable for the consequent action Signature of the applicant # The choice can be Block Primary Health Centers, Rural Hospitals, State General Hospitals, Sub Divisional Hospitals, District Hospitals or Medical College Hospitals. The lists of Government Hospitals are available on the website http://www.wbhealth.gov.in Application may be filled online or a printed signed copy may be sent by post to- “Dr. Rashbehari Dutta, DDHS (Admn), Swasthya Bhawan, GN-29 Sector-V Salt Lake, Kolkata -700091. “ The envelop should be superscribed as “APPLICATION FOR OUT PATIENT DEPARTMENT CONSULTATION SERVICES” Last Date of submission of application: 10th January, 2017 MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Medical Bankura SMCH Colleges Barddhaman MCH North Bengal MCH Kolkata MCH Kolkata National MCH NRS MCH Kolkata RG Kar MCH Kolkata SSKM Hospital Kolkata Medinipur Medical College & Hospital College of Medicine & Sagar Dutta Hospital Malda MCH Murshidabad MCH College of Medicine & Kalyani JNM Hospital District Bankura Bishnupur DH Hospital Barddhaman Asansol DH Suri Sadar Hosp. Birbhum Rampurhat DH Dakshin Dinajpur Balurghat DH Darjeeling DH Darjeeling Siliguri DH Haora Haora DH Hugli Hooghly DH Jalpaiguri Jalpaiguri DH CoochBihar MJN Hosp. Nadia Nadia DH Barasat DH North 24-Parganas Basirhat DH Paschim Medinipur Jhargram DH Tamluk DH Purba Medinipur MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Purba Medinipur Nandigram DH Puruliya Sadar Hosp.Purulia M.R. Bangur South 24-Parganas Diamond Harbour DH Uttar Dinajpur Raiganj DH SDH Bankura Khatra SD Durgapur SD Barddhaman Kalna SD Katwa SD Birbhum Bolpur SD Dakshin Dinajpur Gangarampur SD Kalimpong SD Darjiling Kurseong SD Howrah Uluberia SD Arambag SD Hooghly Chandannagar SD Srirampur SD Alipurduar SD Jalpaiguri Mal SD Dinhata SD Mathabhanga SD Coochbihar Mekhliganj SD Tufanganj SD Malda Chanchal SD Domkal SD Jangipur SD Murshidabad Kandi SD Lalbag SD Ranaghat SD Nadia MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Nadia Tehatta Barackpur SD North 24-Parganas Bongaon SD Salt Lake SD Ghatal SD Paschim Medinipur Kharagpur SD Contai SD Purba Medinipur Egra SD Haldia SD Purulia Raghunathpur SD Baruipur SD South 24-Parganas Canning SD Kakdwip SD Uttar Dinajpur Islampur SD SGH Belur SG Fort Gloster SG Gabberia SG Howrah South Haora SG TLJ Hospital Lilua Udaynarayanpur SG Hooghly Uttarpara SG Jalpaiguri Birpara SG Chakdaha SG Nadia Nabadwip SG Shantipur SG Asoknagar SG Baranagar SG Bhatpara SG North 24-Parganas Habra SG MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Naihati SG Panihati SG Sri Balaram Seba Mandir Purba Medinipur Digha SG Bagha Jatin SG Bijoygarh SG South 24-Parganas Garden Reach Hospital Vidyasagar SG Uttar Dinajpur Kaliyaganj SG Other Kolkata Abinash Dutta Maternity Home hospitals ( Indira Matri - O - Sishu Kalyan Hospital SGH) Lady Dufferin Victoria Hospital North Subarban Hospital Sambhunath Pandit Hospital North 24 parganas Shibani Arogya Niketan Rural Bankura Amarkanan Hospital Kotalpur Raipur Sonamukhi Taldangra Indus Chhatna Indpur Onda Patrasayer Radhanagar Ranibandh Saltora Sarenga MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Amjhuri Anchuri Borjora Simlapal Burdwan Ballabhpur Bhatar Mankar Memari Singot Srirampur Atghoria Ban-Nabagram Bahadurpur Jamalpur Khandra (U) Kelejora Laudoha Madhabdihi Maheshbati Monteswar Paharhati Panagarh Pithaikeary Purbasthali Pursha Ramjibanpur Birbhum Baswa Illambazaar Md. Bazar MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Mollarpur Nalhati Nanoor Nakrakonda Paikar Rajnagar Satpalsa Sultanpur Dubrajpur Labpur Murarai Sainthia Dakshin Dinajpur Hili Harirampur Khaspur Kumarganj Kushmandi Rashidpur (Bangshihari) Tapan Darjeeling Bijanbari Kharibari Naxalbari Phansidewa Rambi Pedong Mirik Sukna Takdah Howrah Bagnan MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL B. B. Dhar Domjur Jagatballavpur Amta Brindabanpur Chandipur-Manickpur Hazi S. T. Mullick Jagadishpur Jhumjhumi Kamalpur Kulai Mugkalyan Hooghly Chanditala Dhaniakhali Haripal Jangipara Khanakul Pandua Singur Tarakeswar Ahmedpur Akuni Ichhapasar Dakshin Narayanpur Kamarpukur Kanaipur Mogra Natibpur Polba Akri Srirampur MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Jalpaiguri Bhatibari RH Dhupguri RH Falakata Mainaguri Rajganj Belacoba Jasodanga Kamakshyaguri Madarihat Panchkalguri Sulkapara Uttar Latabari Coochbihar Haldibari Bamanhat Dewanhat Goksadanga Natabari Pundibari Sitai Sitalkuchi Malda Bangitola Bamangola R.N. Roy Gazole Harishchandrapur Manikchak Ariadanga Bedrabad Hatimari MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Malatipur Masaldabajar Milki Moulpur Ratua Silampur Murshidabad Anupnagar Bharatpur Godhanpara Gokarna Kanapukur Mahesail Saktipur Salar Amtala Beldanga Burwan Islampur Jiaganj Khargram Krishnapur Sadikhan's Dear Sagardighi Nadia Aranghata Bishnupur Dhubulia Jadab Dutta Habibpur Maheshganj Pritimayee (Palashipara) MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Bagula Chapra Kaliganj Karimpur Krishnaganj Bethuadahari Nathidanga Haringhata North 24 Parganas Amdanga Biswanathpur Chandpara Dhanyakuria Ghoshpur Haroa Maslandapur Nanna Sabdalpur Sandallerbil Rudrapur (Baduria) Bagdah Madhyamgram Minakhan Sarapole Sandeshkhali Taki Reckjoani Paschim Med Binpur Chandrakona Daspur MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Debra Garhbeta Hijli Keshpur Sabang Salboni Bagda(Mohanpur) Belda Belpahari Bhangagarh Dwarigeria Gopiballabhpur Keshiary Kewakole Khandrui Kharikamathani Khirpai Pingla Sonakhali Tapsia Purbo Med Anantapur Basulia Bhagawanpur Reapara Basantia Bararankua Mugberia Erashal Gangadharbhar MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Janubasan Khejurberia Paikpari Patashpur Sillyaberia Uttar Mechogram Purulia Banda Bundwan Barabazar Chakoltor Jhalda Joypur Kolloli Kushtor Muradih Para Pathardihi Puncha Sirkabad Manbazar Bansgarh Harmadih Hura Kotshila South 24 Parganas Amtala Jaynagar L B Dutta Mathurapur Padmarhat MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Raidighi Sagar (Rudranagar) Sonarpur Sree Ramkrishna (Nimpith) Baneswarpur Basanti Banjanherial Charial Dwariknagar Gosaba Jirangacha Madhabnagar Matherdighi Mograhat Naiyarat Nalmuri Panchagram Uttar Dinajpur Karandighi Chakulia Dalua/ Chopra block Hemtabad Itahar Lodhan BPHC Joypur Kanchanpur Bankura Mejhia Simla Adrahati Akalpur Badla MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Barsul Jamtara Ketugram Barddhaman Khandaghosh Kurman Mangalkote Nowapara Raniganj Srikhanda Andal pandabeswar Bara Chaturi Bolpur Birbhum Chakmondala Lohapur Dakshin Dinajpur Mathurapur (Chaloon) Gorubathan Darjeeling Sukhiapokhri Matigara Debipur Howrah Joypur Hugli Goghat Mangalbari Jalpaiguri Odlabari Ashokbari Baxirhat Koch Bihar Changrabandha Gosanimari Tarafrasulfur Ahiron MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Beldanga Hariharpara Karna Subarna Murshidabad Nabagram Nashimpur Teghari Bharathpur Farakka Beniagram Rajnagar Bandipur Chhotojagulia North 24-Parganas Shibhati Sundarpur Chandra Changual Chilkigarh Paschim Medinipur Dantan Mohanpur Vidyasagar Amlat Barghashipur Digha AK Garh Moyna Purba Medinipur Gonara Kamarda Kharipukuria Majna Ramchandrapur Bari Purulia MCH/DH/ SD/SG/RH /BPHC DISTRICT NAME OF THE HOSPITAL Purulia Balitora (Raghunathpur) Chandi Daulatabad Falta Ghutiary Sharif Hariharpur South 24-Parganas Harendranagar kakdwip Kulpi Samali Sarisha Sarsuna Rampur (Raiganj) Uttar Dinajpur Ramganj ( Islampur) Kunor PHC ( kaliyaganj bphc) Other Districts Ramrikdas Haralalka Hospital hospitals Gouripur Leprosy Hospital Beharampur Mental Hospital Calcutta Pavlov Hospital Darjeeling TB Hospital Dr B C Roy Chest Sanatorium Gandhi Memorial Hospital J D T B Hospital K S Roy TB Hospital Lumbinipark Mental Hospital M R Bangur T B Sanatorium, Digri Netaji Subhas Sanatorium. Niramay TB Sanatorium Puruliya Mental Hospital Rani Ashrumati Memorial T B Hospital S B Dey TB Sanatorium Satya Bala Debi ID Hospital* sanction as per Unit sanction GO MCH/DH/ SD/SG/RH /BPHC