State Recruitment Bureau for Co-operatives

Chennai
Application form for Recruitment of Assistant in Co-operative Instutitions 2012-13
PERSONAL DETAILS
Notification No 01. Application No 02. Name of the Candidate 03. Gender 04. Date of Birth 05. Father's Name 06. Mother's Name 07. Marital Status 08. Native District 09. Mother Tongue 10. Nationality 11. Religion 12. Address for Communication : 3 / 2012 SRB : 1026023 : S MEENA : Female : 05 May 1986 : P SUBRAMANI : S KANNAMMAL : Married : COMBATORE : Tamil : Indian : Hindu : 15C, SEDAPALAYAM ROAD, SOMANUR, SULUR (TALUK), COIMBATORE 641668. : SULUR : COMBATORE : TAMILNADU : 641668 : 15C, SEDAPALAYAM ROAD, SOMANUR, SULUR (TALUK), COIMBATORE 641668. : SULUR : COMBATORE : TAMILNADU : 641668 : dharshana662012@gmail.com : 9865902044

13. Taluk 14. District 15. State 16. Pincode 17. Permanent Address

18. Taluk 19. District 20. State 21. Pincode 22. Email Id 23. Mobile No

CERTIFICATES DETAILS
24. Communal Category 25. Name of the Sub-Caste 26. Certificate No 27. Date of Issue 28. Issuing Authority 29. Taluk 30. District 31. Are You a Differently Abled Person? : BC : VISHWA KARMA : 4945562 : 10-Jun-2005 : SPECIAL DEPUTY THASILDAR : COIMBATORE SOUTH : COMBATORE : No

32. Do you need a scribe? 33. Are you an Ex-serviceman? 34. PPO No. 35. Date of Discharge / Probable Discharge 36. Are you a Destitute widow? 37. Are you presently working in any co-operative society or in any other institutions? 38. If so, whether subjected to any surcharge, criminal activities? 39. Case Details

: No : No : N/A : N/A : No : No

: No : N/A

EDUCATIONAL QUALIFICATION PARTICULARS

40. Educational Qualification and Medium of Instruction Qualification
10 +2 Degree

Year of Passing
2003 2005 2008

Medium of Instruction
Tamil Tamil English

Whether studied Tamil as one of the subject? Yes

Yes Yes

41. Centre for Written Examination 42. Appointment Option Option I II III District
1. 11 - COMBATORE 2. 11 - COMBATORE 3. 11 - COMBATORE

: 11 - COMBATORE Institutions
6 - CENTRAL CO-OPERATIVE BANKS 9 - DISTRICT CO-OPERATIVE UNIONS 17 - OTHER TYPES OF COOPERATIVE SOCIETIES

PAYMENT DETAILS
43. Demand Draft No 44. Payment Date 45. Bank Name 46. Bank City 47. Bank Branch 48. Amount : 756053 : 12-Nov-2012 : UNION BANK OF INDIA : COIMBATORE : SOMANUR : 250 Declaration I hereby declare that all the particulars furnished in this application are true, correct and complete to the best of my knowledge and belief. 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 State Recruitment Bureau for Cooperatives

Date :

15-Nov-2012 11:09:58 AM

Signature of the Applicant