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ON-LINE APPLICATION FOR COMMON WRITTEN EXAM FOR CLERICAL CADRE

38043
Registration # : 2005665662

Full Name :

PARMAR DINESH SAMA TBHAI

Category : If Person with Disability : Type of Disability : Percentage of Disability : Do you intend to use the services of a scribe (only for VI & OC both hands affected by cerebral palsy) ? : Whether you Children / family members of those who died in 1984 riots? : Whether you domiciled in Kashmir Division of the State of J&K during the period 1-1-1980 to 31-12-1989? : Whether you belong to Religious Minority Community ? : Religion to which you belong : Are you an Ex-Serviceman ? : Are you a disabled Ex-Serviceman (DISXS)? : Are you a dependent of an Ex-Serviceman killed in action ? : Have you passed in one of the following Armed Forces Examinations equivalent to Civil Examination of HSc/Pre-University? : IAF Education Test for Promotion to rank of Corporal : Passing Out (Indian Navy) Examination conducted by Boys Training Establishment, Visakhapatnam :

OBC NO NA NO NO NO NO NO NO

NO NO

Are you a matriculate Ex-Servicemen candidate, who has obtained the Indian Army Special Certificate of Education or corresponding Certificate in the Navy or the Air NO Force after having completed not less than 15 years of service in Armed Forces of the Union? : Are you seeking relaxation under widow / divorced women / women judicially Separated from their husbands and who are not re-married? : Whether Regular Employees of the Union Carbide Factory, Bhopal, retrenched from service (applicable to Madhya Pradesh state only)? : Nationality : State/ UT which the Centre of Examination Belongs : State / UT Code : Centre of Examination : Centre Code : Application Fee / Intimation Charges details: Payment Mode: NEFT UTR No : Sending Bank Name : City : Deposit Date : Amount : NEFT 260911C804993 BANK OF INDIA JAMNAGAR 26-09-2011 350 NO NO INDIAN Gujarat 21 Jamnagar 136

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Personal Details : Date of Birth : Age completed as on 01.08.2011 : Gender : Husband's Name/Father's Name : Mother's Name : Address for Correspondence : 17-08-1989 21 MALE PARMAR SAMATBHAI PUNABHAI PARMAR BAGHIBEN SAMATBHAI NAZ CINEMA ROAD B/H RAILWAY STATION SIKKA JAMNAGR District State : Pin : Permanent Address : JAMNAGAR GUJARAT 361140 NAZ CINEMA ROAD B/H RAILWAY STATION SIKKA JAMNAGR District State : Pin : Contact Details : Email ID : Phone No : Mobile No : Qualification Details (as on 01.08.2011): Exam Passed SSC/Equivalent : HSC/Equivalent : Graduation/Equivalent : Other Details : Would You like to undergo Pre-Exam Training (SC/ST/Minority Community/ ExServicemen /PWD) : If Yes, Centre for Training : Languages Known ENGLISH HINDI GUJARATI --Read YES YES YES Write YES YES YES Speak YES YES YES Subject /Stream GENERAL COMMERCE COMMERCE Date of Passing 31-05-2005 31-05-2007 31-03-2010 % of Marks 67.14 72.71 59.63 parmar.dinesh50@yahoo.com 9662546282 JAMNAGAR GUJARAT 361140

DECLARATION:
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 untrue or incorrect at any stage or my not satisfying any of the eligibility criteria stipulated, my candidature is liable to be cancelled.

Place: Date: 28-09-2011 Signature of Applicant

Please retain your Registration No. and Password emailed to you carefully for further reference NOTE: Please DO NOT SEND application printout to IBPS