APPLICATION FROM

(1) Advt. No. :_____________________________________________________

(2) Name of the post : ______________________________________________
(3) Name of the applicant (in block capital letters) :
________________________________________________
(4) Fathers Name :
__________________________________________________________________________
(5) Date of Birth and age as on 1st February 2014 :
_________________________________________________
(6) Religion :
________________________________________________________________________________
(7) Present Postal address for communication :
____________________________________________________
____________________________________________________
____________________________________________________
(8) Permanent Address : ____________________________________________________
____________________________________________________
____________________________________________________

(9) Telephone Number/ Mobile Phone No. :

_______________________________________________________
(10) e-mail address if any
:_____________________________________________________________________
(11) Academic / Professional qualification in the following Performa
Exam
Institution /
Year of
Class /
Passed
University
Passing
Division

Main Subjects

% of
Marks

(12) Whether Undergone any specialized training , if so, the details :

Name of the Factory /
Period of
Name of the Training
Organization
Training
From

To

Month and
year of
Passing

Remarks

(13) Details of past and present experience with reference to job specification specified in the
advertisement :
Name of the Factory /
Period of service Designatio Nature of
Total salary Reason
Organization
n
duties
(per month) of
From
To
draw
leaving

(14) Whether SC/ST/OBC/PWD/Ex-serviceman (Attach copy of certificates from competent Authority

in prescribed format) :
____________________________________________________________________
(15) Type of Disability and % of Disability :
__________________________________________________
(16) Whether belong to be land affected Category (attach all relevant documents as per General
Condition No.9
(17) Employment Exchange Registration No. ________________ valid up to ___________________
Name of the Employment Exchange ____________________________________________________

(18) Demand Draft No. ____________________ & date ____________________________________

(19) Declaration :
The information submitted above are true /correct and based on documents and at any stage of
recruitment it is found that information submitted by me is false or not correct my candidature will be
liable to be cancelled

Date : ______________

Signature of the applicant