ManasaMitra - Faculty Application Form

ManasaMitra is a holistic mental wellness initiative under SHRADHA, launched by Shri. Muhammed Muhassin, M.L.A

Section 1: Personal Information

Full Name Date of Birth Age Gender

Male Female Others

Marital Status Mother's Name Mobile Number Alternate Contact Number Email Address Full Residential Address Pincode Post Office

Section 2: Location Details

District Taluk Local Body Legislative Assembly Constituency

Section 3: Educational Background

10th Standard - Institution Percentage of Marks Plus Two Institution Percentage of Marks Degree (UG) Institution Percentage of Marks Post-Graduation (PG) - Institution Percentage of Marks Educational Qualification M.A. Psychology M.Sc. Psychology MSW PG Specialization If Other Year of Passing - 10th Year of Passing - Plus Two Year of Passing - Degree Year of Passing - PG

Section 4: Work Experience

Total Work Experience Name of Organization Designation Duration Nature of Work Volunteer or Internship Experience Yes No If Yes, specify Experience in Govt or Community Programs Yes No If Yes, describe Willing to Travel? Yes No

Section 5: Additional Information

Career Goals Understanding of the ManasaMitra Project Upload Resume Upload Photo

I confirm that all the information provided above is true and correct to the best of my knowledge.

You must confirm that the information provided is true.

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