/For Office use only

.
Application No.
Space for affixing
Date of Receipt recent passport size
photograph.

01 ./Advertisement No. :
02 /Post applied for :

03 ./Post No. :

04 :
/Date & Name of News Paper in which advt. appeared
05 /Name in full ( /IN BLOCK LETTERS) :
06 /Nationality :
/Place of birth (,, , /Village,
07 :
Town, District, State)
26.12.2016 /Date of Birth & Age
08 :
as on 26.12.2016
09 - / /Name of parent/spouse :
10 ( . - :
)/Address for correspondence (in BLOCK
LETTERS with PIN code, Contact Phone No. and e-mail address)

11 /Permanent Address ( :
/in BLOCK LETTERS with PIN code)

12 /Nearest Railway Station :

13 /Category ( /put mark) ( . .
: UR SC PH
/Must be supported by documentary evidence)
. . ...

OBC ST Ex-Service
 / /Educational/Professional Qualification (/ /Starting
14
from SSLC/SSC onwards) ( - /Enclose copies of certificates & Mark lists)

/
/ / / / /
Name of
Name of University / Board Year of Passing / Main Subjects/Specialisation
Exam
Class & % of
marks

/ / , (
,
15
)/Details of previous/present employment/training, if any, in chronological order starting from present
position to backwards (to be supported by documentary evidence)
/ /
Name & Address of the Organization/ (/ Period of Service / /
( / )/Post held (with scale of pay/ Nature of
/ /
/ /State whether salary drawn) duties/experience
From To
Govt. / Quasi Govt. / Private).

16 (14) (15)
,
/If :
your replies to Col. (14 )& (15) do not cover all the period
from school leaving till date, briefly state how you spent the
uncovered period.
 17 ,
:
/If selected, the minimum time required to join the post
18
:
/Any other relevant information you wish to
add including references.

/Declaration
/ /



I affirm that the information given in this application is true and
correct. I also fully understand that if at any stage it is discovered that any attempt has been made by me to willfully conceal or
misrepresent the facts, my candidature may be rejected and my employment will be terminated.

/Date: /Signature of the Candidate