APPLICATION FORM FOR THE POST OF JUNIOR CLERK FOR CUTTACK DISTRICT

1. Name of the candidate (In Block letters) :

Affix
recent
passport
2. Father’s Name/Husband Name:
size
photograph
3. Date of Birth as per H.S.C (In figure and words) :

4. Permanent Address :
(In Block letters)with Full Pin Code

5. Present Address for correspondence :

(In Block letters) with Full Pin Code

6. Whether belongs to (ST/ SC/S.E.B.C) :

7. Educational Qualifications from H.S.C. or Equivalent Examination:

Name of Year of Board/Council/ Full Marks % of

Examination passing University Marks secured marks
secured
2 3 4 5 6 7

8. Whether Ex-Serviceman /Ph. Handicapped/Sports man:

9. List of enclosures (see Para -3 & 9 of the advertisement):
10. Employment Exchange Registration Number & Year:
11. Whether married or un- married:
12. Bank Draft No. _______________ Dt._______________
(Original Bank Draft to be attached)

DECLARATION

I do hereby declare that informations furnished above are true, complete and correct
to the best of my knowledge and belief. I am fully aware that in the event of any
information being found false or incorrect at any stage, my candidature/appointment is
liable to be cancelled/terminated without any notice by the Authority.

Place ……………………

Date……………………..
Signature of the candidate in full.