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Application Form ASI

Application Form ASI

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Published by: Vinoth Vino on Jul 14, 2012
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08/28/2014

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‚r-r«rrr-ý/ANNEXURE-I

‡rŠrrrrrªr rr¤r-r ‚rr¤rrrr STAFF SELECTION COMMISSION
‡rŠ.Ôã.¹ãì.ºã.rr „rr r`-rªrer‡rŠr †Ìãâ ‡rŠ.‚rr.ªr.«r.rr ªrzr. „rr r`-rªrer‡rŠ ‡rŠr ¼ã¦ããê ¹ãÀãèàãã, 2012
EXAMINATION FOR RECRUITMENT OF SUB INSPECTORS IN CAPFs,
AND ASSISTANT SUB INSPECTOR IN CISF -2012.
‡rŠrr¤rr rrªrerr ‡rŠ -rrr`›ªr rr r`c† rr† ‚r-rczrr/ªrrrr-r r`rrrrªr`¤r‡rŠr ‡rŠr ªrrrrrrr-rr rr¸rr‡rŠ rr¸z rr J «rr‡r‹ªr ( ) rr r`rrŒr-r ‡rŠ r`rr† -rrrr ¤rr ‡rŠrrr rr-r ‡rŠr rr¤rrrr ‡rŠª ý
Please read instruction in the Notice of the Examination/Annexure-II carefully. Use Blue or Black ball pen to write in the box ( )

1. rrªrerr ‡rŠ-c ‡rŠr -rrrr / Name of the Examination Centre 2. ‡rŠ-c ‡rŠr z / Center Code

3. „rrrrcrrrª ‡rŠr rr¸ªr -rrrr (‚rrr•rr rr) rrr`›‡rŠrrzr-r rrrrr¤r rrªr rr r`c† rr† -rrrr ‡rŠ ‚r-rªrrª «r¸z ‚rerªr rr r`rrŒr J -rrrr ‡rŠ rr-¤r‡rŠ cr =rrrrr ‡rŠ «rrrr †‡rŠ «rr‡r‹ªr Œrrrrr œr¸z c J
Candidate's Full Name (in English). Write in Capital Letters exactly as in Matriculation Certificate. Leave a box blank between every two parts of the name.


4. r`rr-rr ‡rŠr -rrrr (‚rrr•rr ‡rŠ «r¸z ‚rerªr rr r`rrŒr) / Father's Name (Write in Capital Letters in English)


5. rrr-rr ‡rŠr -rrrr (‚rrr•rr ‡rŠ «r¸z ‚rerªr rr r`rrŒr)/ Mother's Name (Write in Capital Letters in English)

6. •r-rr ‡rŠr -rrªrŒr / Date of Birth

ã䪶ã / Day ½ãÖãè¶ãã/Month ÌãÓãÃ/Year

7. ãäÊãâØã/ Gender
(r` rrŒr- 1 ªªrr †rr 2-¹ãî ÁÓã)
(Write 1-Female & 2- Male)
8. ªrr›r¤r-rr /Nationality
(r` rrŒr- 1 =rrª-rr¤r †rr 2-‚r-¤r )
(Write 1-Indian & 2 - Others)
9. zrr‡rŠ/ Fee
(r`rrŒr- 1 zrr‡rŠ ‡rŠr =rrr-rr-r c¤r , 2-œ¸› ‡rŠr crrrr r`‡rŠ¤rr )
(Write 1-Fee paid & 2- Exemption claimed)
10. Ñãñ¥ããè / Category
(r`rrŒr 9 ‚r-rr,1‚r•rr, 2‚r•r•rr †rr 6 ‚rr`rrrr)
(Write 9-General, 1-SC, 2-ST, 6-OBC)

10.1 ‡r‹¤rr ‚rrrr =r¸-rrr¸rr ªrr`-r‡rŠ z ?
Whether Ex-serviceman ?
(r`rrŒr- 3-=r¸-rrr¸rr ªrr`-r‡rŠ )
(Write 3- Ex-Serviceman)
11. ‡r‹¤rr ‚rr¤r ªrrrrr rr œ¸› rrrz-r z ?
Whether seeking Age relaxation ?
(r`rrŒr 1 Öãú , 2-¶ãÖãé )
(Write -1-Yes, 2-No)
11.1 ¤rr`c zr, ‡rŠrz ‚rr`‡rŠ-r ‡rŠª
If yes, indicate code
(cr ‚r‡rŠr ‡rŠr ªrŒ¤rr-rr‡rŠ ‡rŠrz ‚rr`‡rŠ-r ‡rŠª )
(Write two digit numeric code)
11.2 16.3.2012 ‡rŠr ‚rr¤r(‚rr`-rrr r`-rr`ªr)
Age as on 16.3.2012 ( Closing date)

ÌãÓãà / Years ½ãÖãè¶ãã/ Months ã䪶ã / Days
12.¹ãª ‡rŠ r`rr† rrrªrr`rr‡rŠ-rr [ A,B,C,D,E,F,]
Preference for Posts [ A,B,C,D, E,F, ]
1 2 3 4 5 6


(Please see Instruction)
13. =r¸-rrr¸rr ªrr`-r‡rŠ ‡rŠ r`rr† For Ex-Serviceman
ªrrrr ‚rrrr`rr / Length of Service [ÌãÓãà /Year]
ÔãñÌãã Ôã½ããã书ã ãä¦ããä©ã /Date of Discharge
ã䪶ã / Day ½ãÖãè¶ãã/Month ÌãÓãÃ/Year


14. ‡r‹¤rr ‚rrrr ‚rrrrªrŒ¤r‡rŠ z ?
(‚rrrrªrŒ¤r‡rŠ ‡rŠ r`rr† 8 r`rrŒr J)
Whether belong to Minority Communities
as per Govt. Orders? (Write 8 for minority community)

15. zrr`er‡rŠ ¤rrr¤r-rr Educational Qualification
‡rŠrz ‚rr`‡rŠ-r ‡rŠª Indicate Code

r`rrrr¤r ‡rŠrz
Subject Code
‚r‡rŠr ‡rŠr rrr`-rzr-r(%)
Percentage (%) of Marks




½ã㣾ã½ã (‚rrr•rr-1, ãäÖ¶ªãè -2rr ‚r-¤r-3)
Medium ( English-1, Hindi-2, Others-3)






16. ‡rŠr¤r ‡rŠr ‚r-r=rrr / ãäÌãÌãÀ¥ã Details of work Experience / Govt. Service rendered
ªrªªrr ‡rŠr -rrrr
Name of the Organisation(s)
¹ãª¶ãã½ã
Designation
‡rŠr¤r ‡rŠr r`rrrrª¤r
Name of the Duty(ies)
‡rŠr¤r ‡rŠr ‚rrrr`rr / Period of Service
Ôãñ /From -r‡rŠ / To


17. rr-rr : ‚rrr-r -rrrr ªrr`z-r rrªr r¤rrrzrª ‡rŠr rr¸ªr rr-rr ‚rrr•rr ‡rŠ «r¸z ‚rerªr rr ¤rr r`z-cr rr -rrrr ¤rr
‡rŠrrr «rrrr rr-r ªr r`rrŒr J
Address: Write your complete Communication Address including your
Name in English Capital Letters or Hindi with Blue or Black Ball Pen.











1. „rrrrcrrrª ‡rŠ zª-rrerª(‡rŠrrrr rrªrr› zª-rr`rrr`rr ½ãò)
Signature of the Candidate in the
above Box (Only in running Hand)




















Page 1 of 2







¶ãã½ã
Name__________________________________________________
¹ã¦ãã
Address_______________________________________________
_______________________________________________________
________________________________________________________
________________________________________________________
ãä¹ã¶ã PIN:
17.1 rrr«rrƒrr -r./ Mobile No. : .......................................................
ƒ-½ãñÊã / Email :...................................................................
18. rrŠr›rrrrrrŠ:
4 -|. ·||.x 5 -|.·||. ‚||‡|Š|ª ‡|Š|
,|-| ,| ·| Œ||·|| ·|·|| ·|Š|›|·||·|Š
·|,| Ÿ|‡|Š c·| -| |`·|·|‡|Š|·| ¡
(-›·|-| -| ‡|Šª ¡ ·|Š|›| ‡|Š|
-|.·||`·|.| -| ‡|Šª·||†)
Photograph
Paste here í|rm|y your recent
photograph
(4 cm.X 5 cm)
(Do not stap|e. Do not get the
Photograph attested)
‚|-|‰|Š·||‡|Š(‡|Š·|-| ‡|Š|·||-|·| ·|·||·| ‡|Š |`-|†)
Po|| Number ( íor Oíí|ce use on|y)











20.ÜããñÓã¥ãã / Declaration

·i·. ·i.  i··i· i`··i·· i`·i-i·i·i·i ·i· ·ii· ÷i·i··iº ¡iºi º· i`·i··i ·ii·i ·ii·i i`··i·· t·i :ªii·i
Space for cancellation stamp by post office after affixing CRF stamp































zs. ·i·. ·i.  i··i· i`··i·· ·i·
i`·i¸ :ªii·i
Space for CRF Stamp
r 100.00 ·i·i ·i·.
·i.
 i··i· i` ··i·· ·iti ·i·i· .·i
:i i`·i-i·i·i¸ ·iªii ÷i·i··iº :i
º· ·i·ºi · ·iti :i ·it
ªiºi ·i ·i·ii t
(:·-i·i ·i ·i·º)

Paste here firmly
CRF Stamp of r
100.00
denomination and
get it cancelled from
the post office
where purchased.
( Do not Staple)
(i ) ·|-| ƒ-| ~|.|| ‡|Š |`-|† ‡|Š|ƒ ‚||ª ‚||·|·-| ·|·| -|,| ~|•|| , ·|ª| ·|, ·||-|¸·| , |`‡|Š ·||`· ·| ƒ-| |`-|·|·| ‡|Š| „--|·|-| ‡|Šª.||/‡|Šª.|| ,¸ .|| ‚||·||·|
;|ª| ·|ª| ‚||·|·-| -|ª-|ª| .||ª ·|ª ‚|-·||‡|Š|ª ‡|Šª |`··|| •||†·|| ¡
l have not subm|tted any other app||cat|on íor th|s exam|nat|on. l am aware that |í l contravene
th|s ru|e, my app||cat|on w||| be re|ected summar||y by the Comm|ss|on.
(ii) ·|-| |`·|—||`·.| ·| ·| ·|ƒ º|.|| ‡|Š| ··||-|·|¸·|‡|Š ·|c |`-|·|| ,, ‚||ª ·| †.|·;|ª| „-|‡|Š| ·||-|-| ‡|Šª-| ‡|Š| ·|·|-| ·.||/·.|| ,¸¡
l have read the prov|s|ons |n the Not|ce oí the exam|nat|on careíu||y and hereby undertake to
ab|de by them.
(iii) ·| ·|, ~|| ·||·|º|| ‡|Šª.||/‡|Šª.|| ,¸ |`‡|Š ·| ƒ-| ·|ª|÷|| ·| ·|·|º| ‡|Š |`-|† |`-|·|||`ª.| ‚||·| -||·||,º||` ÷|‡|Š ·||··|.||, ‚|||`· -|·|·|| ·||·|.|| ‡|Š| -|~||
º|.| ‡|Š| ·|¸ª| ‡|Šª.||/‡|Šª.|| ,¸ ¡
l íurther dec|are that l íu|í||| a|| the cond|t|ons oí e||g|b|||ty regard|ng age ||m|ts, educat|ona|
qua||í|cat|ons etc., prescr|bed íor adm|ss|on to the exam|nat|on.
(iv) ·| ·|, ~|| ·||·|º|| ‡|Šª.||/‡|Šª.|| ,¸ |`‡|Š ·|ª| ‚||•|.|‡|Š ‡|Š·|·||ª| ·|·|-| ‚||·||·|/-|·| -||‡|Š -|·|| ‚||·||·| ;|ª| |`‡|Š-|| ~|| ·|ª|÷|| ·| ·|Ÿ-| -| -|,|
ª|‡|Š| ·|·|| , .|ª|| -| ,| ·|ª |`Œ|-||·|Š |`‡|Š-|| ~|| |`·||`·| -·||·||-|·| ·| ‡|Š|ƒ ‚||ª|·| ·|·| -||`·|.| , ¡ ·| ·|, ~|| ·||·|º|| ‡|Šª.||/‡|Šª.|| ,¸ |`‡|Š ·|ª|
-|ª‡|Š|ª| -|·|| -| ‡|Š~|| ~|| ·|Œ||-.| -|,| |`‡|Š·|| ·|·|| , ‚|ª|·|| ,›|·|| -|,| ·|·|| , ‚|ª|·|| ·||`ª·||÷|| ‡|Š ·| ª|-| ·|ª| -|·|| -|·||·.| -|,| ‡|Š| ·|ƒ

l a|so dec|are that l do not stand debarred by SSC/ÜPSC as on date and have never been
conv|cted by any court oí |aw. l a|so dec|are that no charge sheet |s pend|ng aga|nst me |n any
court oí |aw. Further dec|are that l have never been d|sm|ssed or removed írom Govt. Serv|ce or
my serv|ce been term|nated dur|ng probat|on.
(v) * ‚||·| -||·|| ·| œ¸› ·||,-| ·||-| ‡|Š-: -|ª‡|Š|ª ‡|Š ‚|-||`-|‡|Š ‡|Š·|·||ª| ‡|Š |`-|†
·| ·|, ·||·|º|| ‡|Šª.||/‡|Šª.|| ,¸ |`‡|Š ·| ‡|Š-: -|ª‡|Š|ª ‡|Š| †‡|Š ‚|-||`-|‡|Š ‡|Š·|·||ª| ,¸ †·| |`-|·||`·|.| ‚||·||ª ·|ª 3 ·|·| ‡|Š| -|·|| ·|| -|·||‡|Š|-|
‚|·||`·| •|-|| ‡|Š| ·|ª|÷|| -|||`›-| ·| |`-|·|||`ª.| ,, ‚||·|·-| ·|·| •|·|| ‡|Šª-| ‡|Š| ‚||`.|·| |`.||`ª| ·|| „-|-| ·|¸·| ·|¸º| ‡|Šª -|| , ¡
* For Centra| Govt. C|v|||an Emp|oyee seek|ng age re|axat|on.
l dec|are that l am a Centra| Govt. C|v|||an Emp|oyee and comp|eted 3 years oí regu|ar serv|ce or
regu|ar |ength oí serv|ce st|pu|ated |n the Not|ce oí the exam|nat|on on or beíore date oí c|os|ng
oí subm|tt|ng app||cat|on íorm g|ven |n the Not|ce.
(vi) * ‚|-·| |`·|œc| ·|·| -| -|·||`·|.| ‚|~·|ª|| ‡|Š |`-|†
·| ·|, ~|| ·||·|º|| ‡|Šª.|| /‡|Šª.|| ,¸ |`‡|Š ·| „-| -|·|·|·| -| -|·||`·|.| ,¸ |`•|-| ‡|Š||`·|‡|Š †·| ·||`º|÷|º| |`·|~||·| ‡|Š |`·-||‡|Š 8.9.1993 ‡|Š
‡|Š|·||-|·| —||·|-| -| 36012/22/93--ª|| (†-|-||›| )·| |`·||`,.| ‚||·º|| ‡|Š ‚|-|-||ª ~||ª.| -|ª‡|Š|ª ;|ª| -|·||‚|| ·| ‚||ª÷|º| ‡|Š ·|·||•|-| ,.|
|`·|œc| ·|·| ·||-|| ·|·|| , ¡ ·|, ~|| ·||·|º|| ‡|Š| •||.|| , |`‡|Š ~||ª.| -|ª‡|Š|ª ‡|Š||`·|‡|Š |·| ·||`º|÷|º| |`·|~||·| ‡|Š |`·||`~|·| -|º||·|-|| •|| |`‡|Š -|||`›-| ·|
„--||`Œ|.| ,, „-|‡|Š .|,.| „·|ª|‡|‹.| ‡|Š|·||-|·| —||·|-| -|. ‡|Š|-|·| 3 ·| „|`--||`Œ|.| ··||`‡|‹.|·||/·|·|| (‰|Š|·|| -|·|ª ) -| -|·||`·|.| -|,| ,¸ ·| ·|, ~||
·||·|º|| ‡|Šª.||/‡|Šª.|| ,¸ |`‡|Š ·| ·|ª|÷|| ‡|Š| |`·|—||`·.| ‡|Š ·|ª| 4(·|) ‡|Š ‚|-|-||ª |`-|·|||`ª.| ·||ª·| ·| ·|·| ‚|-·| |`·|œc ·|·| -|·|·|| ·|·||º| ·|·| ·|-.|.|
‡|ŠªŠ·||/ ‡|ŠªŠ·|| ¡
*For Cand|date be|ong|ng to OBC.
l dec|are that l be|ong to the commun|ty wh|ch |s recogn|zed as a backward c|ass by the Govt.
oí lnd|a íor the purpose oí reservat|on |n serv|ces as per order conta|ned |n Deptt. oí Personne|
and Tra|n|ng Oíí|ce Memorandum No.36012/22/93-Estt.(SCT) dated 8.9.1993. l a|so dec|are that
l do not be|ong to the person/sect|ons (creamy |ayer) ment|oned |n co|umn 3 oí the schedu|e oí
the OM ment|oned above and mod|í|ed v|de Govt. oí lnd|a DOPT OMs ment|oned |n the Not|ce. l
íurther dec|are that l w||| produce va||d OBC cert|í|cate as per para 4(C) oí not|ce oí the
exam|nat|on |n the prescr|bed íormat.
(vii) ~|¸.|·|¸·| -||`-|‡|Š| ‡|Š |`-|†
·| ·||·|º|| ‡|Šª.||/‡|Šª.|| ,¸ |`‡|Š ·| ·|ª|÷|| |`·|—||`·.| ‡|Š ‚|-|-||ª ~|¸.|·|¸·| -||`-|‡|Š -|·||`·|.| ·||·|.|| ‡|Š| -|~|| º|.|| ‡|Š| ·|¸ª| ‡|Šª.||/‡|Šª.|| ,¸ ‚||ª
·|-| ~|¸.|·|¸·| -||`-|‡|Š ‡|Š ªŠ·| ·| ‡|Š-· -|ª‡|Š|ª ‡|Š ‚|.|·|.| |`-||`·|-| -||ƒc ·| ‡|Š|ƒ ª|•|·||ª ·||·.| -|,| |`‡|Š·|| , ¡
For Cand|date be|ong|ng Ex-Serv|ceman
l dec|are that l íu|í||| a|| the e||g|b|||ty cond|t|on re|at|ng to Ex-Serv|ceman as per not|ce oí
exam|nat|on and l have not ava||ed emp|oyment |n c|v|| s|de under Centra| Government as Ex-
serv|ceman.
(viii) ·| †.|·;|ª| ·|, ~|| ·||·|º|| ‡|Šª.|| /‡|Šª.|| ,¸ |`‡|Š ƒ-| ‚||·|·-| ·|·| ·| |`·† ·|† -|~|| |`·|·|ªº| ·|ª| ‚||`·|‡|Š.|·| •||-|‡|Š|ª| ‚||ª |`·|º·||-| ‡|Š
‚|-|-||ª -|.·|, ·|¸º| †·| -|,| , ¡ ·| -|·|ª|.||/-|·|ª|.|| ,¸ |`‡|Š ·||`· ƒ-| ·|ª|÷|| -| ·|,-| ·|| ·||· ·| ‡|Š|ƒ ~|| -|¸·|-|| œ·||ƒ ·|ƒ/ª|¸Ÿ| ·|| ‚|-|.·|
·||ƒ •||-| ·|ª ·|| ‚|·||·|.|| ‡|Š| ·|.|| -|·|-| ·|ª ·|ª| ‚|~·||`ª|.||/|`-|·||`‡|‹.| |`-|ª-.| ‡|Š| •|| -|‡|Š.|| , ¡
l hereby dec|are that a|| statements made |n th|s app||cat|on are true, comp|ete and correct to
the best oí my know|edge and be||eí. l understand that |n the event oí any |níormat|on be|ng
íound suppressed/ía|se or |ncorrect or |ne||g|b|||ty be|ng detected beíore or aíter the
exam|nat|on, my cand|dature/appo|ntment |s ||ab|e to be cance||ed.


-ª||-| /P|ace: .............................................
D D M M Y Y
.||ª|Œ| /Date:

* ·||`· -||·|¸ -| ,| .|| ·|, -||ƒ-| ‡|Š|› · ¡
* Str|ke oíí th|s sentence |í not app||cab|e
„··||··||ª ‡|Š ,-.||÷|ª(‡|Š·|-| ·|-||› ,-.||`-||`·| ·|)
S|gnature oí cand|date ( on|y |n runn|ng hand)


‚|,-.||÷||`ª.| ‚||·|·-| ·|·| ‡|Š| |`-|ª-.| ‡|Šª |`··|| •||†·|| ¡
Üns|gned app||cat|on w||| be re|ected

(Page 2 of 2)






21. ‡|Š.~|.º|-‡|Š |`›‡|Š› ‡|Š |`-|†
-ª||-|
Space íor CPF Stamp
Rs. 100.00 ‡|Š| ‡|Š.~|.º|-‡|Š
|`›‡|Š› ·|,| Ÿ|‡|Š c·| -| |`·|·|‡|Š|†
.|ª|| c|‡|Š·|ª -| ªr ‡|Šª| · •|,| -|
·|, Œ|ª|·| ·|·|| , ¡
(-›·|-| -| ‡|Šª)
Paste here í|rm|y CPF
Stamp oí Ps. 100.00
denom|nat|on and get
|t cance||ed írom the
post oíí|ce where
purchased.
( Do not Stap|e)
‡|Š.~|.º|-‡|Š |`›‡|Š› |`·|·|‡|Š|-|
‡|Š ·||· c|‡|Š·|ª ;|ª| ªr |`‡|Š·|
•||-| ·||-| |`›‡|Š› ,.| -ª||-|
Space íor cance||at|on
stamp by post oíí|ce
aíter aíí|x|ng CPF stamp







(vii) ¼ãî¦ã¹ãîÌãà Ôãõãä¶ã‡ãŠãò ‡ãñŠ ãäÊㆠ½ãö ÜããñÓã¥ãã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîú ãä‡ãŠ ½ãö ¹ãÀãèàãã ãäÌã—ãã书㠇ãñŠ ‚ã¶ãìÔããÀ ¼ãî¦ã¹ãîÌãà Ôãõãä¶ã‡ãŠ Ôãâºãâãä£ã¦ã ¹ãã¨ã¦ãã ‡ãŠãè Ôã¼ããè Íã¦ããô ‡ãŠãñ ¹ãîÀã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öúî ‚ããõÀ ½ãõ¶ãñ ¼ãî¦ã¹ãîÌãà Ôãõãä¶ã‡ãŠ ‡ãŠñ ÀŠ¹ã ½ãñâ ‡ãŠñ¶ªÆ ÔãÀ‡ãŠãÀ ‡ãŠñ ‚ãâ¦ãØãæã ãäÔããäÌãÊã Ôãメ ½ãñâ ‡ãŠãñƒÃ Àãñ•ãØããÀ ¹ãÆ㹦㠶ãÖãèâ ãä‡ãŠ¾ãã Öõ ñý For Candidate belonging Ex-Serviceman I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of examination and I have not availed employment in civil side under Central Government as Exserviceman. ‚ããÌãñª¶ã ¹ã¨ã •ã½ãã ‡ãŠÀ¶ãñ ‡ãŠãè ‚ãâãä¦ã½ã ãä¦ããä©ã ¾ãã „ÔãÔãñ ¹ãîÌãà ¹ãî¥ãà ‡ãŠÀ Êããè Öõ ý * For Central Govt.ÜããñÓã¥ãã / Declaration ‡ãñŠ. D D M M Y Y ¦ããÀãèŒã /Date: * ¾ããäª ÊããØãî ¶ã Öãñ ¦ããñ ¾ãÖ ÊããƒÃ¶ã ‡ãŠã› ªò ý * Strike off this sentence if not applicable ‚ãÖÔ¦ããàããäÀ¦ã ‚ããÌãñª¶ã ¹ã¨ã ‡ãŠãñ ãä¶ãÀԦ㠇ãŠÀ ã䪾ãã •ãã†Øãã ý Unsigned application will be rejected (Page 2 of 2) ....00 ‡ãŠã ‡ãñŠ.. ( Do not Staple) 23. £É. my candidature/appointment is liable to be cancelled....00 denomination and get it cancelled from the post office where purchased. BÉEä.. (vi) * ‚㶾ã ãä¹ãœü¡ã ÌãØãà Ôãñ Ôãâºãâãä£ã¦ã ‚ã¼¾ã©ããê ‡ãñŠ ãäÊㆠ½ãõâ ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠÀ¦ãã /‡ãŠÀ¦ããè Öîúâ ãä‡ãŠ ½ãõâ „Ôã Ôã½ãìªã¾ã Ôãñ Ôãâºãâãä£ã¦ã Öúî ãä•ãÔãñ ‡ãŠããä½ãÇ㊠†Ìãâ ¹ãÆãäÍãàã¥ã ãäÌã¼ããØã ‡ãŠñ ã䪶ããâ‡ãŠ 8. ‚ãããäª Ôãâºã£ããè ¹ãã¨ã¦ãã ‡ãŠãè Ôã¼ããè Íã¦ãó ‡ãŠãñ ¹ãîÀã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîú ý I further declare that I fulfill all the conditions of eligibility regarding age limits.. „½½ããèªÌããÀ ‡ãñŠ ÖÔ¦ããàãÀ(‡ãñŠÌãÊã ÜãÔããè› ÖÔ¦ããäÊããä¹ã ½ãò) Signature of candidate ( only in running hand) Ô©ãã¶ã /Place: . ¶ÉÖãBÉE ãäÊㆠÉ{ÉBÉEÉxÉä BÉEä ‚ããÌãñª¶ã ¹ã¨ã ¶ãÖãé ÉÊB •ãã Öõ ½ãì BÉÉãÉä ÉÊ] ½ããÊãî ºlÉÉxÉ ´ãÀã ½ãñÀã for cancellation stamp‚ãÔÌããè‡ãŠãÀofficeªafter affixing CRF stamp Space ‚ããÌãñª¶ã ÔãÀÔãÀãè ¦ããõÀ ¹ãÀ by post ‡ãŠÀ ãä ¾ãã •ãã†Øãã ý I have not submitted any other application for this examination.. „Ôã‡ãñŠ ¦ã֦㠄¹ãÀãñ‡ã‹¦ã ‡ãŠã¾ããÃÊã¾ã —ãã¹ã¶ã Ôãâ..9. I also declare that I do not belong to the person/sections (creamy layer) mentioned in column 3 of the schedule of the OM mentioned above and modified vide Govt...¼ã.9... (iii) ½ãö ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîâ ãä‡ãŠ ½ãö ƒÔã ¹ãÀãèàãã ½ãò ¹ãÆÌãñÍã ‡ãñŠ ãäÊㆠãä¶ã£ããÃãäÀ¦ã ‚ãã¾ãì Ôããè½ãã.....Íãìʇ㊠Paste here firmly CRF Stamp of Rs.(SCT) dated 8......00 BÉEÉ BÉEä. Civilian Employee seeking age relaxation. Service or my service been terminated during probation.20.36012/22/93-Estt. ¹ãî¥ãà †Ìãâ ÔãÖãè Öõ ý ½ãõâ Ôã½ã¢ã¦ãã/Ôã½ã¢ã¦ããè Öîâ ãä‡ãŠ ¾ããäª ƒÔã ¹ãÀãèàãã Ôãñ ¹ãÖÊãñ ¾ãã ºã㪠½ãñâ ‡ãŠãñƒÃ ¼ããè ÔãîÞã¶ãã œì¹ããƒÃ ØãƒÃ/¢ãîŸãè ¾ãã ‚ãÔ㦾㠹ããƒÃ •ãã¶ãñ ¹ãÀ ¾ãã ‚ã¹ãã¨ã¦ãã ‡ãŠã ¹ã¦ãã ÊãØã¶ãñ ¹ãÀ ½ãñÀãè ‚ã¼¾ããä©ãæãã/ãä¶ã¾ãìãä‡ã‹¦ã ãä¶ãÀԦ㠇ãŠãè •ãã Ôã‡ãŠ¦ããè Öõ ý I hereby declare that all statements made in this application are true. I declare that I belong to the community which is recognized as a backward class by the Govt... my application will be rejected summarily by the Commission. ‡ãŠãùÊã½ã 3 ½ãò „ãäÊÊããäŒã¦ã ̾ããä‡ã‹¦ã¾ããñâ/ÌãØããô (‰ãŠãè½ããè Êãñ¾ãÀ ) Ôãñ Ôãâºãâãä£ã¦ã ¶ãÖãèâ Öîú ½ãö ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîú ãä‡ãŠ ½ãõ ¹ãÀãèàãã ‡ãŠãè ãäÌã—ãã书㠇ãŠñ ¹ãõÀã 4(Øã) ‡ãŠñ ‚ã¶ãìÔããÀ ãä¶ã£ããÃãäÀ¦ã ¹ãÆãÁ¹ã ½ãò Ìãõ£ã ‚㶾ã ãä¹ãœü¡ñ ÌãØãà Ôãâºãâ£ããè ¹ãƽãã¥ã ¹ã¨ã ¹ãÆÔ¦ãì¦ã ‡ãŠÀŠâØãã/ ‡ãŠÀŠâØããè ý *For Candidate belonging to OBC. ‡ãñŠ. 100.Íãìʇ㊠ã䛇㊛ ãäÞã¹ã‡ãŠã¶ãñ ‡ãñŠ ºã㪠¡ã‡ãŠÜãÀ ´ãÀã Àÿ ãä‡ãŠ¾ãñ •ãã¶ãñ ÌããÊãñ ã䛇㊛ Öñ¦ãì Ô©ãã¶ã Space for cancellation stamp by post office after affixing CRF stamp 21. of Personnel and Training Office Memorandum No.. of India for the purpose of reservation in services as per order contained in Deptt.¼ã. I declare that I am a Central Govt. ( Do not Staple) (i ) ½ãö¶ãñ ƒÔã ¼ã¦ããê ‡ãñÉÊŠ]BÉE] ÉÊS‡ãŠãñƒÃ ‚ããõÀ ¤ÉÉn bÉBÉEPÉ® uÉ®É ®q ¼ãñÉEªÉä VÉÉxÉä ¢ãñ ¾ãÖ BÉE] cä½iãÉÖ Öõ ãä‡ãŠ ¾ããäª ½ãö ƒÔã ãä¶ã¾ã½ã ‡ãŠã „ÊÊãâÜã¶ã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öúî ¦ããñ ‚ãã¾ããñØã BÉEä. I further declare that I will produce valid OBC certificate as per para 4(C) of notice of the examination in the prescribed format. 100. complete and correct to the best of my knowledge and belief. educational qualifications etc. ¶ÉÖãBÉE ÉÊ]BÉE] ªÉcÉÄ ~ÉÒBÉE fÆMÉ ºÉä ÉÊSÉ{ÉBÉEÉAäÆ iÉlÉÉ bÉBÉEPÉ® ºÉä ®q BÉE®É nå VÉcÉÄ ºÉä BÉc JÉ®ÉÒnÉ MɪÉÉ cè * (º]ä{ÉãÉ xÉ BÉE®å) Paste here firmly CRF Stamp of r 100. £É.. Civilian Employee and completed 3 years of regular service or regular length of service stipulated in the Notice of the examination on or before date of closing of submitting application form given in the Notice..... ¶ÉÖãBÉE ÉÊ]BÉE] BÉEä ÉÊãÉA ºlÉÉxÉ Space for CRF Stamp r 100.Íãìʇ㊠ã䛇㊛ ‡ãñŠ ãäÊㆠԩãã¶ã Space for CRF Stamp ã䛇㊛ ¾ãÖãú Ÿãè‡ãŠ ¤âØã Ôãñ ãäÞã¹ã‡ãŠã†â ¦ã©ãã ¡ã‡ãŠÜãÀ Ôãñ Àÿ ‡ãŠÀã ªò •ãÖãú Ôãñ ÌãÖ ŒãÀãèªã Øã¾ãã Öõ ý (Ô›ñ¹ãÊ㠶㠇ãŠÀò) Rs. Further declare that I have never been dismissed or removed from Govt... (viii) ½ãõâ †¦ãªá´ãÀã ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠÀ¦ãã /‡ãŠÀ¦ããè Öîúâ ãä‡ãŠ ƒÔã ‚ããÌãñª¶ã ¹ã¨ã ½ãñâ ã䪆 ØㆠÔã¼ããè ãäÌãÌãÀ¥ã ½ãñÀãè ‚ããä£ã‡ãŠ¦ã½ã •ãã¶ã‡ãŠãÀãè ‚ããõÀ ãäÌãÍÌããÔã ‡ãŠñ ‚ã¶ãìÔããÀ Ô㦾ã.1993. prescribed for admission to the examination.1993 ‡ãŠñ ‡ãŠã¾ããÃÊã¾ã —ãã¹ã¶ã Ôãâû 36012/22/93-Ô©ããû (†ÔãÔããè›ãè )½ãò ãäÌããä֦㠂ããªñÍããò ‡ãñŠ ‚ã¶ãìÔããÀ ¼ããÀ¦ã ÔãÀ‡ãŠãÀ ´ãÀã ÔãñÌãã‚ããò ½ãò ‚ããÀàã¥ã ‡ãñŠ ¹ãƾããñ•ã¶ã Öñ¦ãì ãä¹ãœü¡ã ÌãØãà ½ãã¶ãã Øã¾ãã Öõ ý ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠãè •ãã¦ããè Öõ ãä‡ãŠ ¼ããÀ¦ã ÔãÀ‡ãŠãÀ ‡ãŠããä½ãÇ㊠ãÌãâ ¹ãÆãäÍãàã¥ã ãäÌ ã¼ããØã ‡ãñŠ ãäÌããä¼ã¸ã ÔãâÍããñ£ã¶ããò •ããñ ãä‡ãŠ ¶ããñãä›Ôã ½ãò „ÊÊãñãäŒã¦ã Öõ.. I understand that in the event of any information being found suppressed/false or incorrect or ineligibility being detected before or after the examination. I also declare that no charge sheet is pending against me in any court of law. £É. ‚ããõÀ ½ãö †¦ãªá´ãÀã „¶ã‡ãŠã ¹ããÊã¶ã ‡ãŠÀ¶ãñ ‡ãŠã ÌãÞã¶ã ªñ¦ ãã/ªñ¦ããè Öîúâý I have read the provisions in the Notice of the examination carefully and hereby undertake to abide by them... (v) * ‚ãã¾ãì Ôããè½ãã ½ãò œî› ÞããÖ¶ãñ ÌããÊãñ ‡ãñŠ¶³ ÔãÀ‡ãŠãÀ ‡ãñŠ ‚ãÔãõãä¶ã‡ãŠ ‡ãŠ½ãÃÞããÀãè ‡ãñŠ ãäÊㆠ½ãö ¾ãÖ ÜããñÓã¥ãã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîâ ãä‡ãŠ ½ãö ‡ãñŠ¶³ ÔãÀ‡ãŠãÀ ‡ãŠã †‡ãŠ ‚ãÔãõãä¶ã‡ãŠ ‡ãŠ½ãÃÞããÀãè Öîú †Ìãâ ãä¶ã¾ããä½ã¦ã ‚ãã£ããÀ ¹ãÀ 3 ÌãÓãà ‡ãŠãè ÔãñÌãã ¾ãã ÔãñÌãã‡ãŠãÊã ‚ãÌããä£ã •ãõÔãã ‡ãŠãè ¹ãÀãèàãã ¶ããñãä›Ôã ½ãò ãä¶ã£ããÃãäÀ¦ã Öõ..... (iv) ½ãö ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîú ãä‡ãŠ ½ãì¢ãñ ‚ãã•ã¦ã‡ãŠ ‡ãŠ½ãÃÞããÀãè Þã¾ã¶ã ‚ãã¾ããñØã/ÔãâÜã Êããñ‡ãŠ ÔãñÌãã ‚ãã¾ããñØã ´ãÀã ãä‡ãŠÔããè ¼ããè ¹ãÀãèàãã ½ãò ºãõŸ¶ãñ Ôãñ ¶ãÖãé Àãñ‡ãŠã Øã¾ãã Öõ ¦ã©ãã ¶ã Öãè ½ãñÀñ ãäŒãÊãã¹ãŠ ãä‡ãŠÔããè ¼ããè ãäÌããä£ã ¶¾ãã¾ããÊã¾ã ½ãñâ ‡ãŠãñƒÃ ‚ããÀãñ¹ã ¹ã¨ã Êãâãäºã¦ã Öõ ý ½ãö ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîâ ãä‡ãŠ ½ãì¢ãñ ÔãÀ‡ãŠãÀãè ÔãñÌãã Ôãñ ‡ãŠ¼ããè ¼ããè ºãŒããÃԦ㠶ãÖãé ãä‡ãŠ¾ãã Øã¾ãã Öõ ‚ã©ãÌãã Ö›ã¾ãã ¶ãÖãé Øã¾ãã Öõ ‚ã©ãÌãã ¹ããäÀÌããèàãã ‡ãñŠ ªãõ Àã¶ã ½ãñÀãè ÔãñÌãã Ôã½ã㹦㠶ãÖãé ‡ãŠãè ØãƒÃ Öõý I also declare that I do not stand debarred by SSC/UPSC as on date and have never been convicted by any court of law.. of India DOPT OMs mentioned in the Notice.. I am aware that if I contravene this rule..¼ã.Íãõãäàã‡ãŠ ¾ããñؾã¦ãã..00 denomination and get it cancelled from the post office where purchased. (ii) ½ãö¶ãñ ãäÌã—ãã书㠽ãò ªãè ØãƒÃ Íã¦ããô ‡ãŠãñ £¾ãã¶ã¹ãîÌãÇ㊠¹ãü¤ ãäÊã¾ãã Öõ.

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