5/18/2018 Print Application Form

HARYANA PUBLIC SERVICE COMMISSION

Advertisement, Post & ChallanDetails For Office Use Only

Advertisement No. : 1 Space for Marking

: Naib Tehsildar {(Apprentices)
Name of Post
Gazetted Class-II (Group-B)
Registration No. : 2218055606
Challan Detail
Journal No. :
Amount : 125
Bank Name : State Bank of India Signature of Marking Officer

Candidate Particulars :
1 Candidate Name : TARUN
2 Father's Name : RAJESH KUMAR
3 Mother's Name : POONAM DEVI
4 Date of Birth : 08/07/1995
5 Age as per Advt. : 22 Years 5 Months 24 Days
Correspondence Address :
6 Address : HOUSE NO 717 SECTOR 23
HUDA BHIWANI Haryana-
127021 Please fix the
Permanant Address : Original Photo
before submitting
7 Address : HOUSE NO 717 SECTOR 23 to the HPSC
HUDA BHIWANI Haryana-
127021
Personal Details :
8 Have you passed Hindi/Sanskrit upto Matriculation : Yes
9 Nationality : Indian
10 Gender : Male
11 Marital Status : Un-Married
:
12 Are you domicile of Haryana ? : Yes
13 Have you ever been debarred by UPSC/HPSC/OTHERS State PSC : No -
or any other Govt. Dept. ?
Have you ever been convicted by Criminical court ? : No -
Are you employed in Govt/Public sector undertaking?(If yes and : No
14 you are in regularar service then give details and have to submit
NOC from the employer at the time of interview).

15 Are you children or grand children of freedom fighter of Haryana ? : No

16 Are you ESM/DESM :
Contact Details :
17 Contact Number : 9416593761
18 EmailID : tarunduggal411@gmail.com
Extra-Co-Curricular Activities :
19 Extra-co-curricular/sports activities :
20 NCC, NSS, cultural activities :

Category Detail For The Post:

21 Post Claim Category : SC of Haryana
22 Fee Claim Category : SC of Haryana
23 Age Claim Category : SC of Haryana
Candidate Bank Detail:
24 Bank Name : STATE BANK OF INDIA
25 Bank Number : 30870486142
26 Bank Branch : mini secretariat bhiwani
27 IFSC code : SBIN0011864
28. Qualification Details :
Qual. Passing Marks Total
Examination Board/University Subjects % Div
Name Year Obtain Marks
Matriculation 10th H.B.S.E ALL 2011 473 500 94.60 1
Intermediate NON C.B.S.E MATHS PHYSICS 2013 439 500 87.80 1

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5/18/2018 Print Application Form
MEDICAL CHEMISTRY
ENGLISH
PHYSICAL
EDUCATION
UNIVERSITY OF
Graduation B.Sc DELHI , RAMJAS CHEMISTRY HONS. 2016 2725 3550 76.76 1
COLLEGE

29. Experience Details :

Nill

Declaration :
(To be signed by the candidate)
I. All statements made in this application form are true, complete and correct 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 (Preliminary, Main or on selection), my candidature
may be cancelled and action can be taken against me by the Commission.
II. I have read the advertisement, instructions to candidates and provisions in the Brochure of the
Commission related to this examination carefully and I hereby undertake to abide by them. I fulfill
all the conditions of eligibility regarding age limit, educational qualifications etc. prescribed for
admission to the examination in the advertisement, instructions for candidates, provision of
Brochure and other relevant rules and instructions.

Candidate Signature
TARUN
Name in capital letters

Place :
Date : 17/05/2018 [ Signature of the Candidate ]
(Before submitting the form to HPSC)

Note : Incomplete and unsigned application form shall be rejected.

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