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UNION PUBLIC SERVICE COMMISSION

DETAILED APPLICATION FORM
COMBINED MEDICAL SERVICES EXAMINATION, 2019

RID. : 11927571817
Roll No. : 1000704
Name : AYESHA FATHIMA
Email : ayeshafathima123.af@gmail.com
Mobile : 9573982761

1. Name | AYESHA FATHIMA

2. (a) Address for correspondence to which | 5-3-244

communication is to be sent: | AHMEDPURA
Post Office: | KARIMNAGAR,TELANGANA,505001.
City: | KARIMNAGAR
District: | KARIMNAGAR
State : | TELANGANA
Pin Code : | 505001
(b) Telephone No. with STD Code | -
(c) Mobile No. | 9573982761
(d) Fax No. |
(e) E-mail address | AYESHAFATHIMA123.AF@GMAIL.COM
(f) Permanent Postal Address | 5-3-244
| AHMEDPURA
Post Office: | KARIMNAGAR,TELANGANA,505001.
City: | KARIMNAGAR
District: | KARIMNAGAR
State : | TELANGANA
Pin Code : | 505001

3. (a) Citizenship : | A CITIZEN OF INDIA(1)

(b) Nationality : | INDIAN

4. Gender : | FEMALE

5. Marital Status : | UNMARRIED

6. Mother Tongue | URDU

7. (a) Date of Birth | 26-10-91

(b) claimed age relaxation. Upload scanned
copy of documentary evidence in support
of your claim. | No

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8. Place of Birth :
If born in India: | YES
Post Office | KARIMNAGAR,TELANGANA,505001
City/Town/Village | KARIMNAGAR
District | KARIMNAGAR
State | TELANGANA
Pincode | 505001

9. (a) Community | GENERAL (4)

Note 1: Candidate belonging to OBCs but coming in the 'Creamy Layer' and thus not being entitled to OBC
reservation should indicate their community as 'General Category(others)(Code No.4)'.
Note 2: Candidates belonging to neither SC,ST,OBC Communities nor EWS should write 'General'
Category(Others) Code No.4' against the column of community and not leave it blank.'.
Note 3: No change in the community status already indicated by candidate in his / her application form for this
examination will be allowed by the Commission except in the circumstances mentioned in the Rule 21
of Combined Medical Services Examination Rules, 2019.
Note 4: In case you are a 'SC, ST or OBC'(Non Creamy Layer) or EWS candidate, upload a scanned copy of
certificate in support of your claim. For SC, ST, OBC (Non Creamy Layer) candidates, it should be
issued prior to the date of closure of online application form for Combined Medical Services
Examination, 2019 (i.e. prior 06.05.2019). For EWS candidates, it should be issued prior to
1st August, 2019.
Note 5: Candidates belonging to OBC non creamy layer category will have to fill OBC proforma online.
(b) Certificate No. |
(c) Date of issue |
(d) Designation of issuing authority |
(e) Full address of issuing authority |

(f) Name of the Caste as mentioned in the |

Community Certificate and Name of | ()
the issuing State

(g) State your religion if you belong to

Scheduled Caste / If OBC, state
Creamy or Non Creamy Layer |
(h) If you belong to any of the minority
Communities notified by the Government
(Muslim/Christians/Sikhs/Budhists/
Zoroastrians[Parsi]/Jains) | YES
(i) If yes, Name of the Minority
community | MUSLIMS

10.1. Whether you are a candidate with

Benchmark Disability (upload a
scanned Certificate of disability) | NO

10. 2. Have you ever been recommended as a | NO

(a) PH/PwBD candidate in the
examinations conducted by the UPSC
in the past?

(b). If yes, mention name and year of the examination(s) with Roll No.
Name of Examination Year of Examination Roll No.

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(c) Whether such recommendation was on | NO
the basis of the Disability Certificate
NOW UPLOADED by you for the
COMBINED MEDICAL SERVICES
EXAMINATION, 2019?
(d) After any such recommendation by the | NO
UPSC were you ever found UNFIT/
NOT RECOMMENDED by the Central
Standing Medical Board or any other
Medical Board constituted by the
Government with regard to your
physical disability?
(e) If yes, provide details thereof |

11. (a) Name of Father | KHAJA ZAHEERUDDIN

(b) Name of Mother | MERAJ FATHIMA
(c) Nationality of Father | INDIAN
(d) Nationality of Mother | INDIAN
(e) Father's present postal Address | 5-3-244
(If deceased give last address) | AHMEDPURA
Post Office: | KARIMNAGAR,TELANGANA,505001.
City: | KARIMNAGAR
District: | KARIMNAGAR
State : | TELANGANA
Pin Code : | 505001
(f) Mother's present postal Address | 5-3-244
(If deceased give last address) | AHMEDPURA
Post Office: | KARIMNAGAR,TELANGANA,505001.
City: | KARIMNAGAR
District: | KARIMNAGAR
State : | TELANGANA
Pin Code : | 505001
(g) Father's Profession: | INDUSTRY/OWN BUSINESS/SELF EMPLOYED
(h) Mother's Profession: | HOUSEWIFE
(i) If your Father is in service,the post held
by him (if retired, please specify and
indicate the post held by him at the
time of his retirement) | SMALL SCALE PRODUCTION AND SUPPLIER OF
CARWASH
(j) If your Mother is in service,the post held
by her (if retired, please specify and
indicate the post held by her at the
time of his retirement) | NONE
(k) Annual income of your Father | RS.92000
(l) Annual income of your Mother | RS.0
(m) State to which your Father originally | TELANGANA
belongs
(n) District to which your Father originally | KARIMNAGAR
belongs
(o) State to which your Mother originally | TELANGANA

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belongs
(p) District to which your Mother originally| KARIMNAGAR
belongs
(q) Whether your family owns or possesses
any of the following assets.
i) 5 acres of agricultural land and above| NO
ii) Residential flat of 1000 sq ft. and
above | NO
iii) Residential plot of 100 sq. yards and
above in notified municipalities | NO
iv) Residential plot of 200 sq. yards and
above in areas other than the notified
municipalities | NO

12. What Languages(including Indian Languages) can you read/write or speak ? Give particulars and state the
examination(s) passed, if any, for each :-
Read Only Speak Only Read & Speak Read, Write & Examination(s)
Speak passed
ARABIC URDU TELUGU,HINDI,ENGLI
SH.

13. (a) Do you possess the prescribed Educational

Qualification (Vide rule-6 of the rules of the examination).
Please upload a scanned copy of the Certificate
if answer is "YES" | YES

(b) Certificate No. | 131368

(c) Date of issue | 23-05-2018
(d) Designation of issuing authority | REGISTRAR.
(e) Full address of issuing authority | REGISTRAR,DR.NTR UNIVERSITY OF HEALTH
SCIENCES,VIJAYAWADA,ANDHRA PRADESH.

Note: If you do not possess the prescribed educational qualification as mentioned in rule of the
examination your candidature is liable to be cancelled. The proof of passing the requisite examination
should be dated earlier than the due date(closing date) of Detailed Application Form of the Combined
Medical Services Examination, 2019.

(f)(i) Do you have any Educational Qualification

or higher qulification obtained from a foreign
institution? | NO

14. Educational Qualifications : Commencing with Matriculation or equivalent examination till Graduation:-
Examination Class/ Percentage CGPA Year of Subject(s) Name of Name of
Passed Division of Score Out of School/College Board/University
/Grade Marks(%) Passing /Institution
10th or Equivalent First 88.5 2007 Telugu,Hindi,English Trinity Model Board Of Secondary
,General Secondary School,Ped Education,Andhra
science,Social dapally,Karimnagar,T Pradesh.
Studies,Mathematics elangana.
12th or Equivalent First 90 2010 Arabic,English,Botan Trinity Girls Junior C Board Of
y,Zoology,Physics,Ch ollege,Karimnagar,Tel Intermediate
emistry. angana. Education,Andhra

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Pradesh.
Stream at Graduation Level :-- MEDICAL
Graduation or First 70.08 2018 MBBS Chalmeda Anand Rao Dr.NTR University
Equivalent Institute Of Medical S Of Health Sciences,
ciences,Karimnagar,T Vijayawada,Andhra
elangana. Pradesh.

15. (a) Whether passed written and practical

parts of final MBBS Examination : | YES
(b) Date of written and practical part of
final MBBS Examination : | 25-03-2017

16. (a)Whether completed Rotating

Internship: | YES
(b) Date of completion of compulsory
Rotating Internship : | 29-03-2018
(c) Likely Date of completion of
Internship : | 29-03-2018

17.(i) Were you ever employed? : | NO

18. Please give Particulars of:-

(a) Prizes,medals scholarships,that you |
have been awarded.
(b) Team/Games/Sports/N.C.C. |
/Hitchhiking/Mountaineering etc.
(c) Position(s) of distinction / Leadership |
held in School/College
(d) Other extra curricular activities and | COOKING,MEHENDI ART.
interests (Such as hobbies etc.)

19. In case you are considered for appointment to CMS, your order of preference for various Zonal Railways
for which you would like to be considered .

Zonal order of Preference

S.N. State Cadres Order of Preference
1. FIRST PREFERENCE SOUTH CENTRAL RAILWAY
2. SECOND PREFERENCE SOUTH WESTREN RAILWAY
3. THIRD PREFERENCE SOUTHERN RAILWAY
4. FOURTH PREFERENCE SOUTH EASTREN RAILWAY
5. FIFTH PREFERENCE SOUTH EAST CENTRAL RAILWAY

20. Your order of preference against the Services/Posts given below,for which you wolud like to be
considered for appointment.

S.N. Name of Services/Post Order of Preference

1. Central Health Service (Junior Scale posts in Central Health Service) 2
2. Railways (Assistant Divisional Medical Officers in the Railways) 1

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3. General Duty Medical Officer in New Delhi Municipal Council. 3
4. General Duty Medical Officer Gr.II in East Delhi Municipal Corporation, North 4
Delhi Municipal Corporation and South Delhi Municipal Corporation.

21. Photo-ID Proof | AADHAR CARD (XXXXXXXX6324)

22. Have you ever been debarred by

any Public Service Commission or
Staff Selection Commission from
any of their Examinations/Selections? | NO

23. Whether you have been selected or

applied for U.P.S.C. Examination
/Recruitment:- | YES
Details of other application for Examination/Recruitment held/to be held by UPSC :-
Name of Examination/Post Month and Roll. No. Whether Whether Whether Whether continuing
year of Ex you you you were r till date or
amination / appeared appeared ecommend resigned(with date)
Advt./Item at the Exa at the ed for appo
No. for Re mination Interview intment
cruitment
UPSC CMSE JULY 2018 0 YES NO NO NA

24. State of Domicile | TELANGANA

25. List of Enclosures uploaded by the candidate:-

--->Scanned Copy of proof of date of birth as prescribed in Para below Note IV under Rule 5 of the rules
for the exam.
--->Scanned Copy of the certificate of educational qualifications (including a copy of recognition letter /
equivalence certificate from AIC/UGC, if applicable)

Roll No. :- 1000704 |

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DECLARATION TO BE SIGNED BY THE CANDIDATE

I, hereby declare that all statements and entries made in columns 1 to 25 of this application are true,
complete and correct to the best of my knowledge and belief.

I have read rule 11 of the Rules of the Examination published in Part-I, Section-I of the Gazette
of India dated 10th April, 2019 and understand that in the event of any information being found false
or incorrect or ineligibility being detected before or after the examination, action can be taken
against me by the Commission.

I further declare that I fulfill all the eligibility conditions regarding age limits, educational qualifications
etc. prescribed for admission to the Examination.

I have not withhold any information required as per this Detailed Application Form.

I have thoroughly scrutinised the list of scanned documents as enumerated in column 25 of the DAF
and uploaded scanned copies of all the documents relevant for me.

I have read the rules and instructions carefully and I hereby undertaken to abide by them.

* I have informed my Head of the Office/Department in writing that I have applied for this examination.

Signature of the Candidate

Name : AYESHA FATHIMA
Roll No.: 1000704

Place:
Date:

[Note: Online submission of the DAF by the candidate within prescribed time period is
construed as his/her signed applicaion]

*Strike of this sentence, if not applicable.

**Application not signed by candidate is liable to rejection.

Roll No. :- 1000704 |

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UNION PUBLIC SERVICE COMMISSION
SUMMARY SHEET
(FOR OFFICE USE ONLY)
DATE:-
SESSION:-
ROLL NUMBER :- | 1000704
NAME OF EXAMINATION :- | COMBINED MEDICAL SERVICES EXAMINATION, 2019
NAME :- | AYESHA FATHIMA
DATE OF BIRTH :- | 26-10-91

PLACE OF BIRTH :-
If born in India: | YES
Post Office | KARIMNAGAR,TELANGANA,505001
City/Town/Village | KARIMNAGAR
District | KARIMNAGAR
State | TELANGANA
Pincode | 505001

Please give Particulars of:-

(a) Particulars of prizes,medals scholarships,etc. |
(b) Team/Games/Sports/N.C.C. |
/Hitchhiking/Mountaineering etc.
(c) Position(s) of distinction Leadership held in |
School/College
(d) Other extra curricular activities and interests (Such | COOKING,MEHENDI ART.
as hobbies etc.)

Educational Qualifications : Commencing with Matriculation or equivalent examination till Graduation:-

Examination Class/ Percentage CGPA Year of Subject(s) Name of Name of
Passed Division of Score Out of School/College Board/University
/Grade Marks(%) Passing /Institution
10th or Equivalent First 88.5 2007 Telugu,Hindi,English Trinity Model Board Of Secondary
,General Secondary School,Ped Education,Andhra
science,Social dapally,Karimnagar,T Pradesh.
Studies,Mathematics elangana.
12th or Equivalent First 90 2010 Arabic,English,Botan Trinity Girls Junior C Board Of
y,Zoology,Physics,Ch ollege,Karimnagar,Tel Intermediate
emistry. angana. Education,Andhra
Pradesh.
Stream at Graduation Level :-- MEDICAL
Graduation or First 70.08 2018 MBBS Chalmeda Anand Rao Dr.NTR University
Equivalent Institute Of Medical S Of Health Sciences,
ciences,Karimnagar,T Vijayawada,Andhra
elangana. Pradesh.