PUNJAB STATE CIVIL SUPPLIES CORPORATION LIMITED

(A State Govt. Undertaking)

APPLICATION FOR THE POST OF___________________________________

1.(a) Category(Please mark ( ) tick in the appropriate box

wherever applicable)
SC
Please affix one recent
GEN OTHERS MAZ/BALMIKI BC
photograph duly attested
by Gazetted Officer
(b) Sub Category
ESM PH FF SPORTS
B/LW HI LD/CP

Abbreviations: GEN-General, SC-Scheduled Caste, Maz- Mazhbi, BC-Backward class

ESM-Ex-Serviceman, PH-Physically Handicapped, B-Blindness, LV-Low Vision, HI-
Hearing Impairment LD- Locomotor Disability, CP- Cerebral Palsy ,
FF-Freedom Fighter, Sports-Sportsperson.
(Signature of the Candidate)

2. Fee - DD / Date Amount

Banker's Cheque No.

3. Have you passed Punjabi upto Matriculation Standard? YES NO

4. (a) Have you passed 120 Hrs.Computer Course as per essential qualification? YES NO

(b) Whether you possess a degree of Bachelor in Engineering/

YES NO
B.Tech./Master in Engineering/ M.Tech./ M.B.A./ M.C.A. and
thus claim exemption from passing 120 hours computer course?

5. Percentage of Marks Obtained in Qualifying examination

6. Experience (wherever applicable)

Years Months Days

7. Sex M F 8. Date of Birth 9. Age as on 31.03.2011

Date Month Year Years Months Days

10. If claiming Age Relaxation

tick the relevant category SC BC ESM PH

11.Candidate's Name(in Capital Letters)(Please leave one box blank between first, middle & surname)

12. Father's Name(in Capital Letters)

13.Mother's Name(in Capital letters)

14. Candidate's Correspondence Address (in Capital Letters)

Name _____________________________________ Please affix one recent

photograph without
Father's/Husband's Name ____________________________________ attestation.

Address ____________________________________

City/Town _____________________________________

State _____________________________________

Pin Code
(Signatures of the Candidate)
15. Candidate's Permanent Address (in Capital Letters)

Name _______________________________________

Father's/Husband's Name ____________________________________

Address _______________________________________

City/Town ________________________________________

State ________________________________________

Pin Code

16. Nationality

17. Are you Married? YES NO

18. If yes, do you have more than one living spouse YES NO

19. Educational and Professional Qualification

Examination Passed Name of Board/University/Institution Year of Percentage of Marks
Passing Obtained

20. (a) Have you ever been dismissed from Govt. service? YES NO

(b) Have you ever been convicted by any Court? YES NO

21. Details of documents attached(Please tick in the appropriate box)

(i) Matriculation Certificate(for proof of age). NO
(ii) Marks sheet of Matriculation (proof of having passed Punjabi)
NO
(iii) Academic/Computer Education/Experience Certificates
NO
(iv) If belonging to SC,BC,ESM,PH,FF Sportsperson category,
attach proof thereof from competent authority. N
(v) Bank Draft/ Banker's cheque. NO

From Serial No. (i) to (iv) above documents should be self-

attested photocopy.

(Signatures of Applicant)
Declaration:-
I, _____________________son/daughter of __________________________ aged ________
years and resident of ______________________________________District_______________(State), hereby
declare that the above and the information given in the attached documents is correct and true to the best of
my knowledge and belief and nothing has been concealed therein. I am aware that in case the information
submitted by me is found to be incorrect or wrong, I shall be liable for punishment under the law and, if
employed, my services shall stand summarily dismissed.

Place:_________________

Date: _________________ (Signatures of Applicant)