ASSAM PUBLIC SERVICE COMMISSION

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Application form Post/Exam. Applied for

Registration No Name of Candidate Father's Name Father's Occupation Mother's Name Gender Nationality Age Condonation Date of Birth Category Are you a Person with disability Disability Type Disability Percentage Present City/Town/Village Present Post Office Present Pin Code Present Police Station Present Sub Division Locality House No./Street Name etc Present State Present District(for Assam only) Present District(for other states) Permanent City/Town/Village Permanent Post Office Permanent Pin Code Permanent Police Station Permanent Sub Division Locality House No./Street Name etc Permanent State Permanent District(for Assam only) Permanent District(for other states) Degree Stream Year Of Passing University Optional Subject Examination Centre COMBINED COMPETITIVE PRELIMINARY EXAMINATION-2013

06111136384
DEBASISH PHUKON DIBAKOR PHUKON ANU PHUKON Male INDIAN NO 22/06/1988 OBC/MOBC NO

Age as on 01/01/2013:

24 Years

NAHARHABI TEA ESTATE LAKWA 785698 SIMALUGURI POLICE STATION

Assam Sivasagar BOKOTA BOIRAGIBOR VILLAGE NANGALAMARA TINIALI 785674 NEMUGURI POLICE STATION

Assam Sivasagar Degree Engineering 09/07/2010 DIBRUGARH UNIVERSITY

Mechanical Engineering Sivasagar

NO NO

Have you ever been debarred from applying for any Government post Have you ever been debarred from any Examination and/or selection conducted by the UPSC or any State PSC: Other Information Details

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Degree
HSLC

Division Percentage of Marks

I 80.33

Year of Passing
08/06/2004

Duration of Degree
3 SEBA

Board/University

HS

75.60

22/05/2006

AHSEC

Degree

72.66

09/07/2010

DIBRUGARH UNIVERSITY

Declaration:
I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. In the event of any information being found false or ineligibility being detected before or after the examination, action may be taken against me as the Commission may deem fit. I have read the terms and conditions of the Commission as published in the advertisement carefully and do hereby undertake to abide by them or any other terms and conditions as may be applicable to me. I further declare that I fulfill all the eligibility conditions prescribed for admission to the examination. I declare that I have not been debarred by the APSC or UPSC or any other State PSCs. I also declare that I am not a dismissed Govt. employee. I have informed my employer in writing that I am applying for this Examination.(Applicable for employed person only). I hereby declare that I will not be a party to any kind of canvassing on my behalf.

Place: Date: 31/08/2013 7.05 PM

Signature of Applicant

NOTE:Please don't send this Application Form to APSC.

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