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Application for Assistant Central Intelligence Officer Grade-II (Executive)Examination-2009-PART-I
1.Code and Name of center for written test(Refer table ‘A’. Application shall be rejected if  boxes left unfilled)Center Code Center Name2.a) Date of BirthDate Month Year  b) Age (As on closing date)Years Months Days Signature of the candidatein box above preferably inBlack ink/ Black ball pen3.Male/ Female (Write ‘M’ for Male, ‘F’ for female)4.a) Whether SC/ ST/ OBC(Write ‘Y’ for Yes, ‘N’ for No)Category with Code1 for SC2 for ST3 for OBC5.i) Whether Ex-serviceman: Yes/Noii) Total Service rendered as Ex-servicemanYears Months Days6.Whether the resident of J&K and seeking age relaxation(Write ‘Y’ for Yes, ‘N’ for No)7.Home State:8.Nationality:9.Educational Qualification (Graduation Onwards)
SINo.Exam PassedSubjects of studyMaximummarksMarksobtained%age of marks
 10. Are you prepared to service anywhere in India (Write Yes/No)11.Name in Full:For office use onlyRoll No.Candidate shouldaffix his/ her recent self attested passport size photograph
 
12.Father’s Name:13.Mailing AddressPin Code14.Permanent Address:Pin CodeI hereby declare that I satisfy the conditions of the eligibility advertised for admission for theexamination. All the information made in this application are true to the best of myknowledge and belief. I am aware that if at any time, it is found that any information givenabove is false or incorrect then my candidature is liable to be cancelled apart from any other legal action deemed fit.Date:Place:Signature of the Applicant
PART-IITo be filled by the Head of Office in which the candidate is serving.(Only for Government Employees)It is certified that:
i)There are no circumstances rendering Shri/Ms………………. unsuitable for appointment as Assistant Central Intelligence Officer Grade-II /Executiveii)He/ She is regularly appointed as ………………………… with effect from………….. and continues to be so employediii)He/ She is permanent (state designation) ……………………….. of the (Name of theDepartment etc.)……… with effect from ……………. and continues to be soemployediv)The information given be Shri/Ms…………. in the application has been verified withreference to his/ her service record and is correctv)No disciplinary proceeding is pending or contemplated against Shri/Ms……………
OFFICE SEAL:…………………………. SIGNATURE:…………………..NAME:………………………….DESIGNATION:……………….DEPARTMENT/ OFFICE…….
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