COMMON APPLICATION FORM

Important Notes: (i) before filling this form, read detailed advertisement carefully. (ii) All entries should be made in capital letters. (iii) Application form should preferably be typed [Please write the Name of Post]

POST FOR WHICH CANDIDATE IS APPLYING

1.

Name (in capital letters)

(for S. No. 1 & 2 please keep one box blank between name, middle name & surname)

2. Father's/Husband's Name (in capital letters) 3. Date of Birth 4. Age as on 01.09.2012

DAY

MONTH

YEAR

YEAR

MONTH

DAY

5.

Gender
[Male/Female]

6.

Marital Status
[Married/Unmarried]

7.
Country

Nationality
By Birth or Domicile

8.

Name of state for which applied

9. Category (write, as applicable)

CATEGORY belongs to SC/ST/OBC/GENERAL

10. Choice of Examination City with code

11. Address for correspondance (in capital letters) Name :

Please affix one recent passport size Photograph without attestation

Father/Husband Name : Address: : City State Mobile No. Email. 12. Academic Qualification (starting with 10+2) . Name of Degree/ Course with stream Board/University Year of Passing : : Pin Code: Tel. No.

Signature of Candidate

Max. Marks

Aggregate Marks Marks Obtained %age of marks

13. Permanent Address (in capital letters) Name :

Father/Husband Name : Address: : City State 14. : : Pin Code:

Application fee: (Rs 1000/- (Rupees one thousand only) is payable in the form of demand draft drawn in favour of INSTITUTE FOR SELECTION OF PROFESSIONALS payable atAGRA

DD No.

Date

Name of Bank

Branch Address

Branch Code

Amount (Rs.)

DECLARATION TO BE SIGNED BY THE APPLICANT I do hereby declare that all the statements made in the application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any particular information given above being found false or incorrect, my candidature for the post of Para Medical Staff is liable to be rejected or cancelled and in the event of any mis-statement or discrepancy in the particulars being detected after my appointment, my services are liable to be terminated forthwith without any notice to me. Place: Date: (Signature of the Applicant)