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ONLY ONLINE APPLICATION WILL BE ACCEPTED FORM IS INDICATIVE

ANNEXURE-I
FOOD CORPORATION OF INDIA

Combined Recruitment for Assistant Grade III in General, Depot, Technical and Account Cadres
in FCI, 2013

... ,, , 2013

BE{ {F BE x] nA MA +xn / BE Bvx {BBE {f *


Please read instructions in the Notice of the Examination/Annexures carefully.
1.

{F BExp BE x / Name of the Examination Centre

2. {F BEx p BEb / Examination Centre Code

3. =nB BE { x (+OV ) ]B Ex |h {j nA MA x BE +x +F J * x BE n M BE S ABE BD BE J U n *

Candidates Full Name (in English). Write in Capital Letters exactly as in Matriculation Certificate. Leave one box blank between every two parts of the name.

4.

{i BE x (+OV BE +F J) / Fathers Name (Write in Capital Letters in English)

5. i BE x (+OV BE +F J) / Mothers Name (Write in Capital Letters in English)

6.

Vx BE iJ / Date of Birth
nx / Day cx /Month

7. M / Gender
(J 1-j AB 2-{)
(Write 1-Female & 2- Male)

/Year

10. gh / Category
(J 9-+x,1 +V,2 +VV AB 6-+{B)
(Write 9-General, 1-SC, 2-ST,
6OBC)
11.1 n c, BEb +BEi BE

If yes, indicate code

(J 4-+.B., 5-g.B.)
(Write 4-OH, 5-HH, 7-VH )

10.1 +{ i{B xBE c

10.2. i {B xBE BE A For Ex-Serviceman

?
If Ex-serviceman

B +Bv / Length of Service

J
Write 3 in the box

,
( 1-,, 2-)

Write A for East, B for West, C for


North, D for South and E for North
East zones.

BE
If yes, indicate code

(n +BE BE JiBE BEb +BEi BE)


(Write two digit numeric code)
14.1 Preference for posts

1
2
3
4

See Note IV of para A3 of the


Notice

15. F BE Mi Educational Qualification


BEb +BEi BE Indicate Code [See Annex III]

(J 1-c AB 2-xc)
(Wrire 1-Yes, 2-No)

cx/Month /year)

11.3 If scribe required medium in which examination will be taken


(Write 1 - English, 2 Hindi)
, ( 1, 2 )

12.2 01.08.2012 BE + / Age as on


01.08.2012

12.1 n c, BEb +BEi

(J 1-c AB 2-xc) (Write -1-Yes, 2-No)

11. BD +{ BE BBEM c ?
Whether PWD ?

[ /Year]
(nx/Day

11.2 If VH, whether scribe is required


(Write 1-yes, 2-No)

Whether seeking Age relaxation?

9. BE / Fee
(J 1-BE BE Mix n 2- U] BE nB B E)
(Write 1-Fee paid & 2- Exemption claimed)

B {i i l/Date of Discharge

12. BD + U] Sci?

14. BE |lBEi Preference for


Zones
1
2
3
4
5

8. /Nationality
(J 1-i AB 2-+x)
(Write 1-Indian & 2 - Others)

/ Years

cx / Months

17

(J 1-c AB 2-xc)

nx / Days

14.2 Are you applying for the post of AG III


(Accounts).
Write 1-Yes, 2-No
-()
1-, 2-
Do you possess qualification for AG III (Accounts). Write
1-yes, 2-No.
-()
1-, 2-

16

Subject Code (See AnnexIV)

13. BD +{ +{JBE c?

+BE BE |i i (%)
Percentage (%) of Marks

Whether belong to Minority Communities


? (Write 1-Yes, 2-No)

14.3 Are you applying for the post of AG III


Technical. Write 1 yes, 2 No.
-( )
1-, 2-
Do you possess qualification for AG III (Technical).
Write 1 yes, 2 No.
-( )
1-, 2-
18
v (+OV-1, cxn-2 B +x-3)
Medium ( English-1, Hindi-2, Others-3)

19. Details of work Experience / Govt. Service BE +xB BE BBh

Name of the Organisation(s) l BE x

Designation {nx

20. {i: +{x x ci {j BBc BE { {i +OV BE +F cxn x


BE {x J *
Address: Write your complete Communication Address including your
Name in English Capital Letters or Hindi with Blue or Black Ball Pen.
Name___________________________________________________
Address_________________________________________________

___________________________________________________________
___________________________________________________________
PIN:
./ Mobile No. : .........................................................

/Email ID:.....

Name of the Duty(ies) BE BE BBh

21. {E] O{E


4 x 5 +BE BE
c c JS M {E]O{E
c ~BE fM S{BE *
(]{ x BE * {E] BE
i{i x BEBA)
Photograph
Paste here firmly your recent
photograph
(4 c.m.X 5c.m)
(Do not staple. Do not get the
Photograph attested)

Period of Service BE BE +Sv


From
To

+xEBE (BEB BE |M ci)


Roll Number (for Office use only)

22.=nB BE ciF (BEB P] ci{ )

Signature of the Candidate in


the left Box (Only in running Hand)
(Page 1 of 2)

23. /Declaration
(i ) /

I have not submitted any other application for this examination. I am aware that if I contravene
this rule, my application will be rejected summarily by the FCI.
(ii) , /
I have read the provisions in the Notice of the examination carefully and hereby undertake to
abide by them.
(iii) / , ,
/
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational
qualifications etc., prescribed for admission to the examination.
(iv) / FCI
/

I also declare that I do not stand debarred by FCI as on date and have never been convicted by
any court of law. I also declare that no charge sheet is pending against me in any court of law.
Further declare that I have never been dismissed or removed from Govt. Service or PSU Service
or my service been terminated during probation.
(v) For FCI Employees seeking age relaxation.
I declare that I am a FCI Employee.
(vi) *
/ 8.9.1993
36012/22/93- ( )

, . 3 / ( )
/

*For Candidate belonging to OBC.


I declare that I belong to the community which is recognized as a backward class by the Govt.
of India for the purpose of reservation in services as per order contained in Deptt. of Personnel
and Training Office Memorandum No.36012/22/93-Estt.(SCT) dated 8.9.1993. 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. of India DOPT OMs mentioned in the Notice. I
further declare that I am in possession of OBC Certificate in the prescribed format given in the
Notice of the examination or will submit valid OBC Certificate at the time of Skill Test/Typing Test
as per the provision of the Notice.
(vii)
/ /
For Candidate belonging Ex-Serviceman
I declare that I fulfill all the eligibility conditions relating to Ex-Serviceman as per notice of
examination and Government of India guidelines.
(viii) /
, / /
/
I hereby declare that all statements made in this application are true, complete and correct to
the best of my knowledge and belief. I understand that in the event of any information being
found suppressed/false or incorrect or ineligibility being detected before or after the
examination, my candidature/appointment is liable to be cancelled.

=nB BE ciF (BEB P] ci{ )


Signature of candidate ( only in running hand)

lx/Place: ..
D

iJ/Date:

* n M x c i c <x BE] n *
* Strike off this sentence if not applicable

+ciFi +Bnx {j BE q BE n VM
Unsigned application will be rejected
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