Sikkim Public Service Commission

GANGTOK 737101, SIKKIM

Affix your recent
stamp size
photograph.
&
1 Extra photo.
Do not pin or staple

APPLICATION FORM FOR THE POST OF

General Duty Medical Officer
(Write in CAPITAL letters only)
ROLL NO. :

(For Office use only)

1.

Name of the Applicant as in the Certificate of Class X Board Examination.

2.

Fathers Name

3.

If Married; Husbands Name

4.

Gender

6.

Place of Birth :

Male

Female

5. Date of Birth & Age :

Date

Month

Village:

City:

District :

State:

Year

Age

7. Address for Communication (do not repeat name)

City

District

Contact No. : Phone :

Pin Code :
Mobile :

8. E-MAIL ID :
9. (a)
(b)

(c)

Category : ( Tick) :

Gen

OBC (CL)

Do you belong to BPL category? if yes,

Certificate No:

OBC (SL)

BL

Issuing Authority:

Whether any of the following category ( Tick) in the appropriate box.

ESM
PWD
SPAE
NONE

ST

SC

Date:

PT

10.

11.

Sl.
No.

12.

Sikkim Subject/Certificate of
Identification No.

Issuing Authority
:

Educational Qualification

Details of Educational Qualifications (from X Standard onwards)

Name of the
Month & Year
Name of the School/college
Qualifying Exam
of Passing
studied

14.

Name of the Board/

University

%
obtained

Permanent Address (do not repeat name)

City

13.

District

District

Employment Card No. :

Pin Code :

Issuing Authority

(a)

Whether employed : ( Tick)

(b)

If employed, nature of appointment : ( Tick) Regular

(c)

If employed, name of the Department :

Details of fee remitted :

Bank Receipt No.
:

Yes

District

No

Dated :

MR

Ad-hoc

Amount :

Contract

Details of Certificates in possession:

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Particulars of Certificates submitted

Certificate Sl. No.

Issuing Authority

Class X Mark sheet

Class X Pass Certificate
Class XII Mark Sheet
Class XII Pass Certificate
Degree Mark sheet
Degree Pass Certificate
Post Graduate Mark Sheet
Post Graduate Certificate
OBC (Central List)/OBC (State List) BL/PT/ST/SC Certificate
Sikkim Subject/Certificate of Identification
If employed, NOC from the employer
Employment Card (renewed)
Unmarried Certificate in case of female candidate (If
necessary)
Incase of married female candidates Husbands C.O.I.
Incase of unmarried female candidates fathers C.O.I.
Certificate of ESM/SPEA/PWD
Certificate of Internship (if necessary)

DECLARATION
I hereby declare that, the information furnished above are true and correct to the best of my knowledge and
belief. In case, any information furnished is found incorrect, incomplete before issuance of Admit Card and or at any
stage of examination, I undertake that my candidature is liable to be rejected.

Signature of the Applicant

Place :
Date :