LIMITED RECRUITMENT (BACKLOG VACANCIES) FOR S.C / S.

T JUNIOR ASSISTANT / TYPIST / OFFICE SUBORDINATE POSTS APPLICATION FORM FOR THE POST OF _______________________.

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Please read the INSTRUCTIONS carefully before filling the application details a) This form must be completed by the applicant in his own hand writing and must be sent with necessary documents to the Collector concerned. b) Applicant in which any portion of the required information is not correctly and completely given will be summarily rejected. c) Application which is received after the due date will be summarily rejected. d) Application in respect of which prescribed documents and certificates in proper form is received after due date will be summarily rejected. e) Application from persons in the service of the Indian Union of a State in Indian or in the employ of local bodies whether they are permanent or approved probationers or probationers or holdings the appointments on temporary or officiating basis which are not sent through the authority competent to appointment them in the posts which they are holding will be summarily rejected. f) Copies of the documents where originals are required to be sent must be certified as correct by a Gazetted Officer or a Magistrate or other responsible person. g) Candidates must make arrangements to see that communications addressed to them at the addresses stated in their applications are redirected, if necessary every effort will be made, by the Collector to take account of chances in Candidates addresses but cannot accept any responsibility in this matter. h) An applicant will be disqualified who attempts to canvas or to bring influence to bear on the Collector / District Selection Committee personally or by a letter. The same penalty will be imposed if any relative, friend, patron, official or other persons attempts to influence the Collector on behalf of the applicant. i) Necessary certified copies wherever necessary should be enclosed.

PERSONAL INFORMATION: 01) Name of the Applicant in full (Capital Letters) 02) Father / Husband Name 03) Address in Full : : :

04) Date of Birth (evidence to produced with attested copy of the document) 05) Place of Birth Village / Town District State 06) Native Place Village / Town District State 07) Is the applicant a citizen of India

: : :

08) Does the candidate belong to SC / ST Category or is he / she parents converted : to Christianity from any of the SC / ST ? If so, please specify (evidence to produced With attested copy of the document) 09) Does the applicant apply for appointment? To more than one service and, if so, Mention order of Preference Preference 1 Preference 2 Preference 3 10) Mother Tongue 11) Other Indian languages known : :

12) Institutions or Institutions where the applicant was educated with dates from VClass onwards Name of the Institution Approximate date Approximate date Examination with full address of entering of leaving passed

QUALIFICATIONS 13) Intermediate or its equivalent Examination (Attested Marks Memo / certificate should enclosed) Register Number Month & Year of passing of Examination Name of the Board Total Marks secured % of Marks

14) Higher educational qualification (Attested Marks Memo / certificate should enclosed) Register Number Month & Year of passing of Examination Name of the University Total Marks secured % of Marks

15) Technical Qualifications: (Attested Marks Memo / certificate should enclosed) Register Number Month & Year of passing of Examination Name of the University Total Marks secured % of Marks

16) Has the applicant rendered war service or is serving with the forces or been invalidated from the war service ? Give the details with dates. (Authenticated extract of the Discharge Certificate to be produced as evidence)

17) Employment Exchange Registration number and place or Registration of the applicant.

I declare that I have not at any time been pronounced unfit for Government service by any medical authority and that the particulars given in this application are correct to the best of my knowledge and belief.

Signature of the Applicant STATION: DATE: