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.
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.