UNION PUBLIC SERVICE COMMISSION

APPLICATION FORM FOR THE CIVIL SERVICES(MAIN) EXAMINATION,2011

1. Roll No. in the Civil Services(Preliminary) Examination,2011
PASTE HERE FIRMLY A
COPY OF YOUR
RECENT PHOTOGRAPH
(approx. 4cm * 5cm)
DULY ATTESTED BY A
GAZETTED
OFFICER/PRINCIPAL OF
THE
COLLEGE/INSTITUTION
LAST
ATTENDED






Roll Number : 272924

2. Details oI Fee paid : Fee to be paid is Rs. 200/-(Female/SC/ST/Physically challenged candidates are not required to pay any fee)
Space Ior aIIixing Central Recuritment Fee Stamps
(This is the sole mode prescribed Ior payment oI Iee)
Name oI Post OIIice / Indian
Mission with complete
address.
Value oI CRF Stamps /
Indian
Mission Receipt

Total Value :
N.B :Indian Postal Orders/Bank DraIt/Money Orders/Crossed Cheque/Treasury Challan/Currency Notes/Postage/Revenue/Court Fee
Stamps etc. are not acceptable.
Roll No :-272924 Candidate Signature
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3.Name (as recoreded in Matriculation /Higher Secondary or equivalent Examination CertiIicate in
BLOCK CAPITALS)
DIPANKAR DAS

4. (a) Address Ior correspondence ( excluding candidate's name) in English BLOCK CAPITALS to
which communication
, FLAT NO. 6, EVELYN
LODGE,ASANSOL
is to be sent.(Please use abbreviations to the extent possible)
, Post Office : UPPER
CHELIDANGA

, District : BURDWAN,
[ State Code : WEST BENGAL
, Pin : 713304
(b) Telephone No. (II any) with STD Code. , -
(c) Fax No. (iI any) ,
(d) E-mail address (iI any) , dipanddgmail.com
(e) Permanent Postal address (iI any) (in BLOCK CAPITALS in English)
, C/O KSHIROD KUMAR
DAS,DAHATI
, Post Office : BARPETA
, District : BARPETA,
[ State Code : ASSAM
, Pin : 781301
,
,
5. WRITE GENDER : , MALE
6. (a) Community :
Community
In words Code No.
SC 1
Scheduled Caste.................................................. 1
Scheduled Tribe.................................................... 2
Other Backward Classes(OBCs) .......................... 3
General Category(Others) ..................................... 4
Note 1: Candidates belonging to OBCs but coming in the "Creamy

Layer" and thus not being entitled to OBC reservation should indicate their community as
"General Category (Others) Code No. 4".


Note 2 :- No Change in community status indicated by a candidate

in his / her application Iorm Ior the civil services (pre.) Examination will ordinarily be allowed
by the commission.


Note:3 :- II SC,ST or OBC enclose a copy oI certiIicate in support
oI your claim.


(b) State your religion iI you belong to S.C(II applicable,please indicate in writing). ,

Roll No :- 272924 Candidate Signature
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(c) II you belong to OBC, please state whether you belong to Creamy Layer or not with
reIerence to the Department oI
,
Personnel and Training O.M No. 36012/22/93-Estt.(SCT) dated 08-09-1993,O.M No.
36033/3/2004--\Estt(Res.)
,
dated 14-10-2008. II not,Please clariIy in OBC proIorma (Annexure 7 oI instruction) as
to why should not be
,
treated as belonging to Creamy Layer with reIerence to each oI the Category I to VI
mentioned in the schedule oI the
,
O.M. dated 8-9-1993 reIerred to above. ,
(d) II you belong to any oI the minority communities notiIied by the Government ( Muslims
/ Christians / Sikhs /
,
Budhists / Zoroastrians (Parsis) , mention the name oI the minority community in the box
opposite.
,
7. (a) Date oI Birth (in Christian Era) as recorded in Matriculation / Higher Secondary or
equivalent examination
, 14-11-86
certiIicate. (Copy oI certiIicate is to enclosed) ,
(b) Do you claim age relaxation in terms oI Rule 6 ? , No
II yes, indicate the appropriate clause(s) oI the Rules and enclose documentary evidence. , Rule No. :-
8. CHOICE OF CENTRE FOR MAIN EXAMINATION :-- , KOLKATA
9. (i)(a) Do you hail Irom Arunchal Pradesh/Manipur/Meghalaya/Mizoram/Nagaland/Sikkim
and are claming exemption
, No
Irom appearing in INDIAN LANGUAGE FOR PAPER I ? ,
II "Yes", please enclose a copy oI the certiIicate Irom the competent authority. ,
(b) II reply to (a) above is "No", indicate INDIAN LANGUAGE FOR PAPER I . , ASSAMESE
(ii) Indicate FIRST OPTIONAL SUBJECT FOR PAPERS VI & VII . , PUBLIC ADMINISTRATION
(iii) Indicate SECOND OPTIONAL SUBJECT FOR PAPERS VIII & IX . , SOCIOLOGY
10.(a) Indicate LANGUAGE MEDIUM OF EXAMINATION FOR ESSAY, GENERAL
STUDIES AND FOR
, ENGLISH
OPTIONAL SUBJECTS as at (ii) and (iii) oI col. 9 above (only ONE language to be
indicated)
,
In case the language medium be Santali or Sindhi, indicate the Script also. ,
(b) Indicate LANGUAGE MEDIUM FOR INTERVIEW TEST, (c.I. para 27 oI the
instrucations to
, ENGLISH
Candidates). ,
Roll No :- 272924 Candidate Signature
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11. Whether passed Degree or equivalent Examination. (Enclose copy oI the ,, Yes
CertiIicate iI answer is 'Yes'. ,,
12. Details oI the Educational Institution attended Irom 1st standard to the last degree:-
Name oI the School /College/Institution Place District State
Class Year
From To From To
Metuakuchi Primary School Barpeta Barpeta ASSAM 1 4 1992 1995
Barpeta Vidyapeeth Higher Secondary School Barpeta Barpeta ASSAM 5 6 1996 1997
Jawahar Navodaya Vidyalaya Howly Barpeta ASSAM 6 11 1997 2003
Jawahar Navodaya Vidyalaya Sorbhog Barpeta ASSAM 12 12 2003 2004
Indian Institute oI Technology Guwahati Kamrup ASSAM
B.
Tech
B. Tech 2005 2009
Roll No :- 272924 Candidate Signature
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13. Particulars oI all examinations passed commencing with matriculation or equivalent examination:-
Examination Passed
Class/Division/
Grade
Percentage
oI marks
Year Subject Name oI School/College
Name oI
Board/University
/Institution
AISSE 1st 88.4 2002
English, Hindi,
Mathematics,
Science, Social
Science
Jawahar Navodaya
Vidyalaya, Barpeta
CBSE
AISSCE 1st 79 2004
English,
Mathematics,
Physics,
Chemistry,
Biology, Work
Experience,
Physical Health
Education, GS
Jawahar Navodaya
Vidyalaya, Barpeta
CBSE
B. Tech 2nd 58.1 2009
Computer
Science
Engineering
IIT Guwahati IIT Guwahati
Roll No :- 272924 Candidate Signature
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14.CITIZENSHIP STATUS (Give correct Code Number (See item V
oI Annexure oI
, 1
Annexure oI instructions to candidates Ior Iilling up this column). ,
15. Marital Status :-- ,
(a) Are you married ? , UNMARRIED
(b) II the answer is "Yes",what is the nationality oI your spouse ? ,
16. (a) Name oI Father , KSHIROD KUMAR DAS
(b) Name oI Mother , CHITRALEKHA DAS
(c) Nationality oI Father , INDIAN
(d) Nationality oI Mother , INDIAN
(e) Father's present postal Address(II deceased give last address) , DAHATI
,
Post OIIice: , BARPETA
District/City : , BARPETA
State : , Assam
Pincode : , 781301
(I) Mother's present postal Address(II deceased give last address) , C/O KSHIROD KUMAR DAS
, DAHATI
Post OIIice: , BARPETA
District/City : , BARPETA
State : , Assam
Pincode : , 781301
(g) Father's ProIession : , BUSINESS
(h) Mother's ProIession : , HOUSE WIFE
(i) II your Father is in service, indicate the post held by him (II
retired, indicate the post
, NA
held by him at the time oI his retirement). ,
(j) II your Mother is in service, indicate the post held by her (II
retired, indicate the post
, NA
held by her at the time oI his retirement). ,
(k) Annual income oI your Father , Rs.36,000
(l) Annual income oI your Mother , Rs.NA

Roll No :- 272924 Candidate Signature
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(m) District and State to which your Father originally belongs , District:-BARPETA, State:-Assam
(n) District and State to which your Mother originally belongs , District:-BARPETA, State:-Assam
17. Place oI birth ,
Town/Village * , BARPETA
District , BARPETA
State , ASSAM
,
18. Indicate your mother tongue , ASSAMESE
Roll No :- 272924 , Candidate Signature
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19. Having regard to answers given against
Columns 12,16,17,and 18,which is the State/Union
Territory that you would claim as your home State/U.T.
, ASSAM
20. In case you are considered Ior appointment to IAS/IPS,indicate your order oI preIerence Ior
various State caders Iorwhich you would like to be considered . (Indicate your Iirst preIerence as 01 and
second preIerence as 02 and so on.)
State Cadres Indicate Your order oI PreIerence

IAS IPS
Andhra Pradesh 10 10
AGMUT 2 2
Assam,Meghalaya 1 1
Bihar 14 14
Chhattisgarh 23 23
Gujarat 13 13
Haryana 4 4
Himachal Pradesh 5 5
Jammu & Kashmir 24 24
Jharkhand 22 22
Karnataka 6 6
Kerala 12 12
Madhya Pradesh 9 9
Maharashtra 7 7
Manipur Tripura 18 18
Nagaland 19 19
Orissa 21 21
Punjab 8 8
Rajasthan 17 17
Sikkim 15 15
Tamil Nadu 20 20
Uttarakhand 3 3
Uttar Pradesh 11 11
West Bengal 16 16

Roll No :- 272924
Candidate Signature
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21. Indicate your order oI preIerence against the Services/Posts given below,Ior which you wolud like to be considered Ior
appointment.(Please write your Iirst perIerence as 1 and second perIerence as 2 and so on ). In case no perIerence is exercised, the word
'NIL shall be indicated against each services(s).'
Name oI Services/Post Order oI PreIerence
Indian Administrative Service 1
Indian Foreign Service 10
Indian Police Service 9
Indian P&T Accounts & Finance Service Group "A" 15
Indian Audit & Accounts Service, Group "A" 8
Indian Revenue Service,(Customs and Central Excise)Group "A" 3
Indian DeIence Accounts Service ,Group "A" 13
Indian Revenue Service, (I.T.) Group "A" 2
Indian Ordance Factories Service,Group "A" (Asstt. Works Manager,Non-Technical) 14
Indian Postal Service,Group "A" 11
Indian Civil Accounts Service ,Group "A" 16
Indian Railway TraIIic Service,Group "A" 5
Indian Railway Accounts Service ,Group "A" 6
Indian Railway Personnel Service,Group "A" 4
Post OI Asstt. Security OIIicer ,group "A" in Railway Protection Force 7
Indian DeIence Estates Service ,Group "A" 12
Indian InIormation Service ,(Junior Grade) Group "A" 21
Indian Trade Service,Group "A" (Grade III) 22
Indian Corporate Law Service ,Group "A" 23
Armed Forces Headquarters ,Civil Service ,Group 'B'(Section OIIicers'Grade) 24
The Delhi ,andaman and Nicobar Island,Lakshadweep,Daman&Diu and Dadra & Nagar Haveli
Civil Service,Group "B"
17
The Delhi ,andaman and Nicobar Island,Lakshadweep,Daman&Diu and Dadra & Nagar Haveli
Police Service,Group "B"
18
Pondicherry Civil Service , Group "B" 19
Pondicherry Police Service , Group "B"
20

Roll No :- 272924 Candidate Signature
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22. Were you ever Employed : - YES
Details oI your employment(in chronological order-till date):-
Desigation Scale oI Pay
Permanent/Temporary/Ad
hoc
Period
Address oI OIIice where employed
From To
No. oI years
months
Management Trainee
Technical
20600-3-
46500
Permanent
31-8-
2009
31-8-
2010
1 Y-0 M
SAIL-IISCO Steel Plant, Burnpur,
West Bengal, 713325
Junior Manager
20600-3-
46500
Permanent
31-8-
2010
Present 1 Y-0 M
SAIL-IISCO Steel Plant, Burnpur,
West Bengal, 713325
* Need not be Iilled, iI you have not been employed so Iar.
Roll No :- 272924 Candidate Signature
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23.(a). Have you ever been debarred by any Public Service Commission or StaII
Selection Commission Irom any oI their Examinations/Selections?
, No
(b). II the answer to above is yes give details. ,
24. Particulars oI prizes,medals,scholarships,etc. ,
Team/Games/Sports/N.C.C. ,
Position(s) oI distinction/Leadership held in School/College ,
SERVED AS HOUSE CAPTAIN FOR 1
YEAR IN 1NV BARPETA, ORGANISED
INTER-COLLEGE ANTAKSHARI
PROGRAM IN ALCHERINGA (ANNUAL
CULTURAL FESTIVAL OF IIT GUWAHATI)
Other extra curricular activities and interests.(Such as hobbies etc.) , Playing Carom, Chess, Surfing Internet
25. (a)
How many times have you appeared at the Civil
Services(Preliminary)Examination so Iar,
, 2
including the current Examination held in May,2011.(Write 1,2,3,4,5....etc. ,
in the opposite box as the case may be) ,
(b)
II you have already appeared at the Civil Services(Preliminary)Examination
held by the UPSC,
, 2009 2011
write year or years oI examination in which you appeared so Iar,including ,
CS(P),2011 in ascending chronological order. ,
26. (a)
Have you ever accepted allocation to a Service/Post on the basis oI a Civil
Service
, No
Commission Examination held in earlier years? ,
(b) II the answer to (a) above is 'yes', indicate:-: ,
(i)
Year oI the Civil Services Examination on the basis oI which you had been
last allocated to service/post :
,
(ii) Name oI service/post to which allocated: ,
(iii) Your Roll No. Ior the examination: ,
(iv) Whether you are continuing in that Service/Post? ,
Roll No :- 272924 Candidate Signature
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27. Whether you have applied / appeared Ior examinations / Recuritment
conducted by upsc ?
NO
Particular oI U.P.S.C Examinations/Recruitments by Selection applied Ior/appeared(including the Civil Services Examination):-
Name oI
Examination/Post
Month and Year oI
Examination/Advt./No.
/Item No.
Ior Recruitment
Roll No
Whether you appeared
at the Examination/Interview
Whether you were
recommended Ior appointment
Roll No :- 272924 Candidate Signature
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28. (a) (i) Indicate whether you are a physically challenged candidate. , NO
(ii) II yes, indicate the category i.e. Orthopaedically/Visually challenged/DeaI mute. ,
(enclose prescribed certiIicate) ,
(c.I.para 22 oI instruction to candidates) ,
(iii) II yes,indicate your percentage oI disability as indicated in certiIicate. ,

Note:-1. For entitlement to reservation as physically challenged,please see Rule 22
oI rules Ior the
,
examination. ,

Note-2. For the deIinition oI "blind" (visually challenged) please see General
Instructions below Appendix-1,
,
Section-II (B) oI rules Ior the examination. ,
(iv) Please speciIy,iI you would require the Iacility oI a scribe in the Examination. ,
(Ior visually challenged candidates only) ,
(v) Please speciIy, iI you would require the extra time oI 20 minutes per hour ,

(applicable Ior L.D.C.P. candidates below appendix I, Section II(B) oI Rules Ior
the examination also see
,
para 22 A oI DAF) ,
(b) Do you claim age relaxation and Iee exemption as physically challenged candidates ? , NO
,
29. List of Enclosures sent by the candidates :--


Central Recruitment Fee Stamps Ior the prescribed Iee paid/exempted.(Please check the box even iI you are exempted)
Attested/CertiIied Copy oI certiIicate oI Age.
Attested/CertiIied Copy oI the certiIicate oI educational qualiIications.
Attested/ Copy oI CertiIicate in Support oI claim to belong to Scheduled Castes/Scheduled Tribes/Other Backward Classes(whereever
applicable).



Roll No :- 272924 Candidate Signature
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DECLARATION TO BE SIGNED BY THE CANDIDATE


I, hereby declare that all statements and entries made in columns 1 to 29 oI this application are true, complete and correct to the
best oI my knowlege and belieI.

I have read rule 14 oI the Rules oI the Examination and understand that in the event oI any inIormation being Iound Ialse or
ineligibility being detected beIore or aIter the examination,
action can be taken against me by the Commission.

I have read the rules and instructions careIully and I hereby undertake to abide by them.


I Iurther declare that I IullIill all the eligibility conditions regarding age limits, educational qualiIications etc. prescribed Ior admission
to the Examination. I have not exhausted the
number oI attempts admissible to me under the rule 4 oI the Rules oI the Examination.

* I have inIormed my Head oI the OIIice/ Department in writting that I am applying Ior this examination.








** Signature oI the Candidate

Place: .....................................................................
Date: ......................................................................

* Strike oII this sentence, iI not applicable.
** Application not signed by candidate is liable to rejection.



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