Online Application Form
Vaccine Logistics and Cold Chain Managers (VCCMs)

1. Personal Details:
Applicant's Name:
Father/Husband's Name:		Date of Birth: (DD/MM/YY)
Gender:		Mobile No.:
Email ID:		Alternate Contact No.:
Domicile:		Category:

2. Address:
Correspondence/ Current Address with Pin Code:		Permanent Address with Pin Code

3. Qualification Detials:
* Name of the Degree/ Diploma	Specialization & Principal Subjects	Name of University/ Institute	Passing Year	Marks (in %)

[+] Additional Qualification: [Please click on (+) sign if you have any other Degree/ Diploma]

4. Work Experience: [Please start with current/ most recent experience. If you have worked in more than one area/ post within the same organization, please enter details of the same separately]:
Name of Organisation	Designation/ Title alongwith Duration [e.g. Immunizaion Officer, June-20015 to June-2016]	Key Responsibilities [Mention atleast 3 key responsibilities]	Experience (in Months)
		*[Maximum Characters allowed: 300]* *You have characters left.*
		*[Maximum Characters allowed: 300]* *You have characters left.*
		*[Maximum Characters allowed: 300]* *You have characters left.*

[+] Add More Work Experience [Please click on (+) for giving more work experience details]

[+] Add More Work Experience [Please click on (+) for giving more work experience details]

5. Details of Relevant Experience:
Name of Organisation (Including Years)	Exposure Area	Details of Experience Possessed	Experience (in Months)
	Experience in IT related projects	*[Maximum Characters allowed: 300]* *You have characters left.*
	Experience in supply chain related projects	*[Maximum Characters allowed: 300]* *You have characters left.*
	Experience in public health/ health care/ vaccine management or cold chain management	*[Maximum Characters allowed: 300]* *You have characters left.*
	Involvement with immunization programmes	*[Maximum Characters allowed: 300]* *You have characters left.*
	Training and capacity building of subordinate staff	*[Maximum Characters allowed: 300]* *You have characters left.*
	Undertaking frequent field visits to monitor status of project implementation and suggest and oversee course corrections by field staff	*[Maximum Characters allowed: 300]* *You have characters left.*

6. Details of Present Compensation (In Rs.):
a. Monthly Salary		b. Monthly Allowances: (If any)

7. Computer Skill:
Application
(1) Knowledge of Windows Operating System & Internet:
(2) Proficiency in use of MS-Office
a. Excel
b. Word and
c. Powerpoint

9. Driving Skills:
(1) Do you have a valid two-wheeler driving license?
(2) Issuing authority
(3) License number

10. Location Preferences: (Please indicate names of your preferences for the state(s) you are applying for:)
State Preference:
State Preference	District Preference 1st	District Preference 2nd

11. References: (Please provide contact details of three references who have supervised you at work:)
	Referee One	Referee Two	Referee Three
Full Name:
Correspondence Address:
Professional Relationship with the referee:
Mobile:
Email ID:

12. Compensation Offered: Gross compensation offered for the position shall be Rs. 22,000/- per month plus Rs. 5,000/- per month towards reimbursement of actual travel costs incurred within the district. The offer made to the selected candidate shall be commensurate with salary history.
Please certify that above mentioned offer is acceptable to you:
13. Joining Documents: Police Verification, Medical Fitness Certificate and Demand Draft of 22,000/ as security deposit against company assets will be submitted as a pre-requisite to joining.
Certification: I certify that to the best of my knowledge and belief, the details submitted by me correctly describe my qualification, experience and other information, as requested by SAMS.