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Annexure-B

izi=&1

lwpuk izkS|ksfxdh vkSj lapkj foHkkx]t;iqj


vkbZ-Vh-Hkou] ;kstuk Hkou ifjlj]fryd ekxZ]lh&Ldhe]t;iqj

lh/kh HkrhZ ,oa vafre p;u gsrq

vkosnd dk
gLrk{kj;qDr
uohure QksVks

foLr`r vkosnu lg&ifjfujh{kk izi=


vkosnd }kjk nks izfr;ksa esa Hkjk tk,

jksy uEcj

vkosnu i= ekad

esfjV ekad

vkWuykbu vkosnui= dk

dsoy vafre ifj.kke gsrq

foKkiu la[;k

in dk uke
lwpuk lgk;d

F2(1512)/DOIT/ESTT./13/I/6214/2013 DT.25.04.2013

lkekU;

fiNM+k
oxZ

fo'ks"k
fiNM+k
oxZ
jkT;

vkj{k.k oxZ
vuqlwfpr vuqlwfpr tutkrh; {ks=
tkfr
tutkfr
ds
,l-lh- ,l-Vhewy fuokl o tUe LFkku
ftyk
rglhy

ckjkWa ftys ds fd'kuxat]


'kkgckn rglhy ds lgfj;k

vU; fVIi.kh

ewy fuokl
tUe LFkku
vfrfjDr fo'ks"k Js.kh vkosnd lacaf/kr dkWye esa **gk ** vafdr djsaA 'ks"k dkWye esa **X** dk fp vafdr djsa

%&

efgyk
vfookfgr

fookfgr

mRd`"V f[kykM+h

fu%'kDr

fo/kok

fofPNUu
fookg

n`f"Vghu@vYin`f"V

ewd cf/kj

vfLFkfor] ,y-Mh-@lh-ih

lsokjr deZpkjh
jkT; lsok deZpkjh

iapk;rh jkt@ lkoZtfud fuxe

foHkkxh; deZpkjh

vjktif=r deZpkjh

ea=kyf;d deZpkjh

1- vkosnd dk iwjk uke %


d fgUnh esa % Jh@Jherh@dqekjh ---------------------------------------------------------------------------------------------------------------------------------------------[k vaxszth esa CykWd ysVlZ esa % Mr./ Mrs./ Miss ------------------------------------------------------------------------------------------------------------------2- v firk dk uke %-----------------------------------------------------------------------------c ekrk dk uke %------------------------------------------------------3- vkosnd dh tUe frfFk% ---------@----------@-------------- 4- foKfIr esa fu/kkZfjr frfFk fnukad 01-01-2014 dks vk;q
% o"kZ --------ekg ---------- fnu -------5- ukxfjdrk %&
Hkkjrh;@vU;-------------------------------- 6- /keZ%& ---------------------------------------------------------------------------------------7- oSokfgd
vfookfgr
fookfgr
fofPNUu
fo/kok
fo/kqj
iqufoZokfgr
fLFkfr%
fookgifjR;Drk
8- fookg fooj.k fookfgr gksus dh fLFkfr esa % --------------------------------------------------------------------------------------------------------------------ifr@iRuh dk uke
fookg frfFk fookg LFkku iath;u la[;k
iath;u LFkku iath;u vf/kdkjh

9- lUrku fooj.k fookfgr gksus dh fLFkfr esa % ----------------------------------------------------------------------------------------------------------------------la1


2
3

thfor iq=@iq=h dk uke

tUe fnukad

-la4
5
6

thfor iq=@iq=h dk uke

tUe fnukad

10- dqy lUrku la[;k 1-6-2002 ls iwoZ %&


1-6-2002 ds i'pkr~ %&
11- i=&O;ogkj dk irk e; Qksu@eksckbZy uEcj % ---------------------------------------------------------------------------------------------------------------------------------12- LFkkbZ fuokl dk iwjk irk %& ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

13- 'kS{kf.kd ;ksX;rk %& v


Exam/ Course

1
Matriculation/
High
School/
Secondary
School
Intermediate/
Higher
Secondary/
Senior
Secondary
Diploma
from
Polytechnic
Post Polytechnic
Deploma
in
Computer
Appilcation
"O" Level or
Higher
Level
Certificate
Courses
Conducted
by
NIIEIT/
DOEACC
Certification in
Computer
Operator
&
Programming
Assistant
(COPA)/
Data
Preparation and
Computer
Software (DPCS)
Organized Under
National/State
Council
of
Vocational
Training Scheme
Graduate Degree
Post-Graduate
Degree
Diploma
Others

Regular/
Distance
Educatio
n
2

Universit
y/ Board

Location
of
University
/ Board
4

Institute/
School
Name with
Address
5

Course
Name
(Major
)
6

Optiona
l
Subjects

Course
Duratio
n

Passin
g
Year*

Percentage
/
Grade
Obtained

10

Status
(Complete
d/Appeari
ng)
11

2 ;fn vki foKkiu ds vuqlkj vf/kdre vk;q lhek esa NwV pkgrs gS] rks izek.k lfgr lac) izko/kku dk
mYys[k djsa ftlds vUrxZr vki vk;q lhek esa NwV izkIr djus ds vf/kdkjh gSaA
layXud la[;k -------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3 ;fn vkidks dHkh lwpuk izkS|ksfxdh vkSj lapkj foHkkx }kjk nf.Mr@inP;qr@CySdfyLV@fooftZr fd;k
x;k gks] rks ml ijh{kk dk uke] o"kZ ,oa mlds dkj.k dk mYys[k djsaA
foHkkx

in @ijh{kk dk uke

o"kZ

dkj.k

&% vkosnd }kjk 'kiFk ;qDr ?kks"k.kk %&

eSa ,rn~ }kjk 'kiFkiwoZd ?kks"k.kk djrk@djrh gw fd bl vkosnu&i= dh lHkh izfof"V;ka o layXu
vfHkys[k esjh O;fDrxr tkudkjh vkSj fookl ds vuqlkj lR; ,oa lEiw.kZ gSaA eSaus dksbZ rF; ugha fNik;k gSA
;fn bl vkosnu&i= esa nh xbZ dksbZ lwpuk >wBh ;k xyr ikbZ tk,] rks lwpuk izkS|ksfxdh vkSj lapkj foHkkx
esjs fo#) fu;ekuqlkj dk;Zokgh dj ldrk gSA eSaus lwpuk izkS|ksfxdh vkSj lapkj foHkkx ds micU/kksas@fu;eksa
dks /;kuiwoZd i<+ fy;k gS vkSj eSa mudk ikyu djus gsrq opuc) gwA
*eSaus vius dk;kZy;@foHkkx ds v/;{k dks fyf[kr :i esa lwfpr dj fn;k gS fd eSa bl in@ijh{kk
ds fy, vkosnu dj jgk@jgh gwA
*eSa ;g Hkh ?kks"k.kk djrk@djrh gw fd esjs fnukad 1&6&02 dks ;k mlds ipkr~ nks ls vf/kd cPps
gaS@ugha gSaA
*tks ykxw uk gks rks mls dkV nsaA
LFkku %& ------------------------------------------fnukad %& ----------------------------------------

vkosnd ds iw.kZ gLrk{kj

layXud lwph
e
la[;k

layXu vfHkys[k fooj.k


LogLrk{kfjr o vfHkizekf.kr QksVks izfr

1. vadrkfydk& eSfVd@gkbZ Ldwy@lSd.Mjh

izi=&2
dkslZ
tkjh
dk
ekad
uke
o
fnukad

layXud la[;k

2. izek.ki=& eSfVd@gkbZ Ldwy@lsd.Mjh


3. vadrkfydk& gk;j lSd.Mjh@ lhfu;j

lSd.Mjh@bUVjehfM,V
4. vadrkfydk& Lukrd

5. mikf/k@izek.ki=& Lukrd

6. vadrkfydk& mikf/k@vf/kLukrd
7. fMIyksek mikf/k@izek.ki=&
8. 'kiFk i= izk:i &4

9. cPpksa ds laca/k esa ?kks"k.kk i= izk:i & 5


10. ngst laca/k esa ?kks"k.kk i= izk:i & 6

11. fookg iath;u izek.k i= ;fn ykxw gks rks


12. oxZ@Js.kh laca/kh izek.k i=

13. ewy fuokl LFkku izek.k i=

14. vfUre f'k{k.k laLFkku }kjk tkjh pfj= izek.k i=

15. 2 jktif=r vf/kdkfj;ksa }kjk tkjh pfj= izek.k&i=


16. iqfyl pfj= lR;kiu izk:i
17. vU; izek.k i=

vkosnd ds gLrk{kj
&% dk;kZy; fVIi.kh %&
vkosnu i= esa vafdr lwpuk dk layXu vfHkys[kksa dh izfr ls feyku fd;k x;k vkSj lgh ik;k x;k@
fuEu deh ikbZ xbZ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------vfHkys[k tkpadrkZ ds gLrk{kj

&% vH;FkhZ dh laf{kIr psd fyLV %&


lac) lwpuk
1- 'kS{kf.kd ;ksX;rk
i vH;FkhZ dh vfuok;Z 'kS{kf.kd ;ksX;rk foKfIr esa
fu/kkZfjr ;ksX;rk ds loZFkk vuq:i gS ;k mlls
fHkUu fdUrq led{k gSA
ii vH;FkhZ us Vad.k xfr ijh{kk dh vafre ifj{kk
fnaukd 05-09-2013 rd vkosnu dh vafre frfFk
dks vfuok;Z 'kS{kf.kd ;ksX;rk izkIr Fkk ;k mlds
ckn izkIr fd;k gS\
2- Js.kh@oXkZ
i vH;FkhZ vkosnu ;k izos'ki= ij vafdr viuh Js.kh
esa gh gS ;k mlls fHkUu Js.kh esa \
ii ;fn vH;FkhZ vkjf{kr Js.kh dk gS] rks D;k og
vkosnu dh frfFk ls iwoZ viuh vkjf{kr Js.kh esa vk
pqdk Fkk ;k mlds ckn lfEEfyr gqvk Fkk\
iii ;fn vH;FkhZ SC/ST/OBC/SBC/Saharia Js.kh
dk gS] rks D;k mlus jktLFkku dk ewy fuoklh
gksus dk lk{; izLrqr fd;k gS\
;fn vH;FkhZ Vh-,l-ih- Js.kh dk gS rks mls Vh-,lih- {ks= ds jktLFkku ds ewy fuoklh gksus dk lk{;
izLrqr fd;k gS\
foks"k;ksX;tu ,oa mRd`"V f[kykMh gS rks D;k
mlus jktLFkku ds ewy fuoklh gksus dk lk{;
izLrqr fd;k gS\

izi=&3

vH;FkhZ lac) dkWye esa fVd djsa

dk;kZy; fVIi.kh

loZFkk vuq:i

mlls fHkUu]
fdUrq led{k

Vad.k xfr ijh{kk dh


vafre frfFk ls iwoZ
izkIr

Vad.k xfr dh vafre


frfFk ds ckn izkIr

mlh Js.kh esa

fHkUu Js.kh esa

vkosnu dh frfFk ls
iwoZ

vkosnu dh frfFk ds
i'pkr~

jktLFkku dk ewy
fuoklh gS

jktLFkku dk ewy
fuoklh ugha gS

3- vk;q
i vH;FkhZ dh foKfIr esa fu/kkZfjr frfFk 01-01-2014 o"kZ -------------ekg -------------- fnu -----------------dks vk;q D;k gS\
ii foKfIr vuqlkj fu/kkZfjr frfFk dks vk;q lhek U;wure--------------------vf/kdre%&------------------21 o"kZ ls 35 o"kZ
iii vH;FkhZ Lo;a dks fuEu esa ls fdl&fdl Js.kh esa -la- --------------------------------------------------ekurk gS\
dz-la1
234-

567891011-

dk;kZy; fVIi.kh

&% vf/kdre vk;q lhek esa fofo/k Jsf.k;ksa@oxksZa ds fy, ns; NwV ds lkekU; izko/kku %&
vH;fFkZ;ksa dk oxZ
vf/kdre vk;q esa ns;
NwV o"kksaZ esa
jktLFkku jkT; ds vuqlwfpr tkfr] tutkfr ,oa fiNM+k oxZ@fo'ks"k
5
fIkNM+k oxZ ds iq:"k
jktLFkku dh vuqlwfpr tkfr] tutkfr ,oa fiNM+k oxZ@fo'ks"k fiNM+k
10
oxZ dh efgyk
lkekU; oxZ dh efgyk
5
fo/kok ,oa fofNUu fookg ifjR;Drk efgyk
dksbZ vf/kdre vk;q
lhek ykxw ugha
lkekU;
10
fu%'kDrtu
fiNM+k@foks"k fiNM+k oxZ
13
v0tk0@v0t0tk0
15
vf/kdre
vk;q lhek
jktLFkku jkT; ds dkjksckj esa laLFkkbZ Substantive :i ls lsokjr
40
o"kZ
O;fDr;ksa] iapk;r lfefr;ksa rFkk ftyk ifj"knksa vkSj jkT; ds ifCyd
lSDVj mieksa@fuxeksa ds dk;Zdykiksa ds laca/k esa laLFkkbZ #i lsokjr
jktLFkku flfoy lsok HkwriwoZ lSfudksa dk vkesyu fu;e] 1988 ds vf/kdre vk;q 50 o"kZ
rgr HkwriwoZ lSfud v/khuLFk lsok gsrq
rd
HkwriwoZ lSfud vkSj fjtfoZLV izfrj{kk lsok ds os deZpkjh] ftudks fjtoZ vf/kdre vk;q lhek
esa LFkkukUrfjr dj fn;k x;k gks
50 o"kZ
lSU; kl@ohj p ;k dksbZ vU; mPp fo'ks"k ;ksX;rk /kkjd HkwriwoZ vf/kdre vk;q lhek
lSfud vkSj fjtfoZLV
52 o"kZ
,u-lh-lh- dSMsV izf'k{kd bULVDVlZ ds ekeys esa vf/kdre vk;q lhek muds }kjk ,ulhlh esa
esa ;fn ifj.kkfed vk;q fofgr vf/kdre vk;q lhek ls 3 o"kZ ls vf/kd
dh xbZ lsok dh
u gks rks mUgsa fofgr vk;q lhek esa gh le>k tk,xk
dkykof/k ds cjkcj
dksbZ vU;

vH;FkhZ
fVd djs

dk;kZy; gsrq

vkosnd ds gLrk{kj
uksV %&
1- mDr izko/kkuksa esa of.kZr vk;q lhek esa NwV ds izko/kku vlap;h(Non Cumulative) gS vFkkZr vH;fFkZ;ksa
dks fdlh Hkh ,d izko/kku es vf/kdre vk;q esa NwV dks ykHk fn;k tk;sxk] ,d ls vf/kd izko/kkuksa dks
tksM+ dj ughaA

ifjfujh{kk fVIi.kh

dk;kZy; mi;ksx gsrq

dk;kZy; esa vkosnu&izkfIr dh frfFk


vkosnd dh Js.kh o miJs.kh
dze la-

1
2
3
4
5
6
7vk;q lhek

vkosnd dk esfjV ekad


fooj.k

gka

ugha

D;k vkosnu&i= LogLrk{kfjr o iw.kZ izfof"V;ksa lfgr izkIr gqvk gS\


D;k gLrk{kfjr QksVks fu/kkZfjr LFkku ij fpidk, gq, gSa\
D;k vkosnd Hkjh xbZ Js.kh oxZ gsrq ik= gS\
D;k vkosnd us fu/kkZfjr frfFk ls iwoZ 'kS{kf.kd ;ksX;rk iwjh dj yh gS\
D;k vkosnd fu/kkZfjr 'kS{kf.kd ;ksX;rk j[krk gS\
D;k vkosnd fu;ekuqlkj vk;q lhek esa gS\
vU; izek.k i= izkIr dj fy, x, gS \
esa NwV pkgus dk dkj.k%& -------------------------------------------------------------------------------------------------------------------------------

&% vfHk'ka"kk %&


7- vkosnd Li"V :i ls lwpuk lgk;d in ds fy, ik= gSA blfy, bUgsa iqfyl pfj= lR;kiu ds
i'pkr dk;Zxzg.k djus dh vuqefr nh tkrh gSA
8- fuEu dkj.kksa ls vLFkkbZ lkrZ dk;Zxzg.k djus ds fy, vuqer fd;k tk,@vik= ?kksf"kr fd;k tk,%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------9- vH;FkhZ nLrkost lR;kiu esa ik=rk laca/kh fuEu folaxfr;k ikbZ xbZ] blfy, lwpuk izkS|ksfxdh vkSj
lapkj foHkkx eq[;ky; dks vafre fu.kZ; gsrq vxzsf"kr fd;k tkrk gSA
1- ---------------------------------------------------------------------2- -------------------------------------------------------------------gLrk{kj

gLrk{kj

gLrk{kj

,-lh-ih- mifuns'kd@
Mh-vkbZ-vks@izksxzkej
lnL;

ys[kk lsok ds vf/kdkjh


lnL;

ofj"Bre vf/kdkjh
nLrkost lR;kiu lfefr

izi=&4

'kiFk i=

uksVsjh }kjk lR;kfir

eSa ----------------------------------------------------------------------iq= @ iq=h Jh -------------------------------------------------------------------------------------- jksy ua- -------------------------------gS] lwpuk lgk;d dh lh/kh HkrhZ ijh{kk&2013 esa lwpuk lgk;d
ds in ij nLrkost lR;kiu gsrq vfHkLrkfor gqvk @gqbZ gwWaA
eSa 'kiFk iwoZd fuEukuqlkj ?kks"k.kk djrk@djrh gWw%&
1-

fd eSa jktLFkku dEI;wVj jkT; ,oa v/khuLFk lsok esa lwpuk lgk;d lh/kh HkrhZ ijh{kk
gsrq visf{kr vgZrk j[krk@j[krh gwaA bl e esa esjs }kjk izLrqr nLrkost oS/k ,oa lR; gS
rFkk laLFkk ftldk izek.k&i= eSus izLrqr fd;k gS] og fu;ekuqlkj gSA eq>s nsoukxjh
fyfi esa fyf[kr fgUnh dk rFkk jktLFkkuh laLd`fr dk Kku gSA

2-

fd esjs }kjk ;ksX;rk@vgZrk laca/kh nh xbZ tkudkjh foKkiu esa vafdr vuqHko@vgZrk ds
vuq:i gSA

3-

fd esjs }kjk izLrqr fd;s x;s vkosnu ls lacaf/kr lHkh nLrkost iw.kZ:i ls lgh gSa ,oa
feF;k@tkyh@udyh@xyr rjhds ls rS;kj djk dj izLrqr ugha fd;s x;s gSA

4-

fd esjs fo:) dHkh Hkh fdlh Hkh Fkkuk{ks= esa dksbZ vkijkf/kd izdj.k u rks ntZ gqvk gS u
gh esjs fo:) fdlh izdkj dh dksbZ vkijkf/kd tkap yafcr gSA esjs fo:) dksbZ
QkStnkjh@U;kf;d izdj.k fdlh Hkh U;k;ky; esa u rks nk;j gqvk gS vkSj u gh yfEcr
gSA

5-

fd esjs }kjk izLrqr fd;k x;k dksbZ Hkh nLrkost fdlh Hkh izdkj ls tkyh@udyh ik;k
tkrk gS vkSj rFkk@vFkok esjs }kjk mDr ?kks"k.kk iw.kZ vFkok vkaf'kd vlR; ik;h tkrh gS
rks ,slh fLFkfr esa eq>s iw.kZ :i ls Kkr gS fd esjh vH;fFkZrk@ik=rk@p;u rqjUr izHkko
ls fujLr dj mlh le; eq>s jktdh; lsok ls i`Fkd dj fn;k tk;sxk] ftlds fy;s eSa
Lo;a iw.kZ :i ls mRrjnk;h jgwaxk@jgwaxhA ,slh fLFkfr esa fu;qfDr izkf/kdkjh dks ;g iw.kZ
vf/kdkj gksxk fd esjs fo:) oS/kkfud@iqfyl@U;kf;d@vuq'kklukRed bR;kfn dh
dk;Zokgh dj ldrs gS] ftlds fy;s eq>s dksbZ vkifRr ugha gksxhA eq>s ;g Hkh Kkr gS fd
fu;qfDr izkf/kdkjh }kjk fu;ekuqlkj vU; ijh{kkvksa esa 'kkfey gksus ls eq>s oafpr (Debar)
fd;k tk ldrk gS] mlds fy;s Hkh eSa gh Lo;a ftEesnkj jgawxk@jgwaxhA

fnukad----------------------------------LFkku-------------------------------------

gLrk{kj--------------------------------------------------------uke ------------------------------------------------------------irk--------------------------------------------------------------------eksckbZy ua---------------------------------------------------

izi=&5

cPpksa ds laca/k es ?kks"k.kk i=


dkfeZd foHkkx dh vf/klwpuk ekad ,Q 71dkfeZdd&2@95 fnukad 20-06-2001
ds vuqlj.k esa fuEufyf[kr izi= esa dk;ZHkkj xzg.k djrs le; ?kks"k.kk tks fd
jktif=r vf/kdkjh ls izekf.kr gS] izLrqr dj jgk@jgh gwWaA
eSa --------------------------------------------iq= @ iq=h Jh -------------------------------------------------------------------------------------jksy ua- -------------------------------gS] lwpuk lgk;d lh/kh HkrhZ ijh{kk&2013 esa lwpuk lgk;d
ds in ij vfHkLrkfor gqvk @ gqbZ gwWa %&
1- fnukad 31-05-2002 rd esjs cPpksa dh la[;k ----------------------------FkhA
-l-

uke

tUe frfFk

2- fnukad 1 twu 2002 dks ,oa blds ipkr esjs cPpksa dh la[;k esa o`f) ugha gqbZ
gSA
;k
fnukad 1 twu 2002 dks ,oa blds ipkr esjs cPpksa dh la[;k esa o`f) gqbZ gS
,oa orZeku esa esjs cPpksa dh dqy la[;k ----------------------------gSA
-l-

uke

tUe frfFk
vH;FkhZ ds gLrk{kj

uke %

--------------------------------------------------------

in

lwpuk lgk;d

esjs le{k gLrk{kj fd;s


jktif=r vf/kdkjh ds gLrk{kj e; eksgj ds

izi=&6

vfookfgr lwpuk lgk;dksa ds }kjk ngst ds laca/k esa izLrqr fd;k tkus okyk
kiFk&i=
eSa ------------------------------------------------------------------- iq=@iq=h Jh --------------------------------------------------------------------fuoklh
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 'kiFk iwoZd ?kks"k.kk djrk@djrh gw fd
lwpuk izkS|ksfxdh vkSj lwpuk foHkkx }kjk tkjh fu;qfDr@inLFkkiu vkns'k ekad --------------------------------------------------------------------------------------- fnukad ------------------------- }kjk dk;kZy; dk iwjk uke------------------------------------------------------------------------------------------------------------------------------------------------------------------ esa lwpuk lgk;d ds in
ij gqbZ gSA
esjk fookg vHkh rd ugha gqvk gS vkSj Hkfo"; esa tc Hkh gksxk rc eSa ;k esjs ?kjokys uk rks
ngst ysaxs @ uk gh ngst nsaxsA Hkfo"; esa ngst fy, tkus ds lEcU/k esa esjh ifRu @ esjs ifr
,oa llqjky i{k dh vksj ls dksbZ fkdk;r foHkkx@U;k;ky; esa ntZ djokbZ tkrh gS rks esjh
fu;qfDr lekIr fd;s tkus dk fu;qfDrdrkZ ;Fkk 'kklu lfpo ,oa vk;qDr] lwpuk izkS|ksfxdh vkSj
lapkj foHkkx] jktLFkku ljdkj dks iw.kZ vf/kdkj gksxk ftlds fy, eSa] izkFkhZ@izkFkhZ;k ftEesnkj
jgwaxk@jgwaxhA
uke&--------------------------------------------------------
?kks"k.kk&drkZ
LFkku%& -----------------------------fnukad%&-----------------------------lk{kh
1-

gLrk{kj ----------------------------------------------------------uke ------------------------------------------------------------------irk -------------------------------------------------------------------------------------------------------------------------------------

2-

gLrk{kj ----------------------------------------------------------uke ------------------------------------------------------------------irk -------------------------------------------------------------------------------------------------------------------------------------

izi=&6

fookfgr lwpuk lgk;dksa ds }kjk ngsr ds laca/k esa izLrqr fd;k tkus okyk
'kiFk&i=
eSa ------------------------------------------------------------------- iq=@iq=h Jh --------------------------------------------------------------------fuoklh
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 'kiFk iwoZd ?kks"k.kk djrk@djrh gw fd
lwpuk izkS|ksfxdh vkSj lwpuk foHkkx }kjk tkjh fu;qfDr@inLFkkiu vkns'k ekad --------------------------------------------------------------------------------------- fnukad ------------------------- }kjk dk;kZy; dk iwjk uke------------------------------------------------------------------------------------------------------------------------------------------------------------------ esa lwpuk lgk;d ds in
ij gqbZ gSA
esjk fookg fnukad --------------------------- dks gqvk gSA fookg ds le; esjs ?kjokyksa us uk rks ngst
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llqjky i{k dh vksj ls dksbZ fkdk;r foHkkx@U;k;ky; esa ntZ djokbZ tkrh gS rks esjh fu;qfDr
lekIr fd;s tkus dk fu;qfDrdrkZ ;Fkk 'kklu lfpo ,oa vk;qDr] lwpuk izkS|ksfxdh vkSj lapkj
foHkkx] jktLFkku ljdkj dks iw.kZ vf/kdkj gksxk ftlds fy, eSa] izkFkhZ@izkFkhZ;k ftEesnkj
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iqfyl pfj= lR;kiu izi= ATTESTATION FORM


Paste your
recent Passport
Size Coloured
Photo with
Signature

1.

Name in full (in block capitals) with


aliases, if any, (please indicate if you
have added or dropped at any stage,
any part of your name or surname

Surname
Name
Roll No.
Merit No.

2.

Present address in full


(i.e. House No. Lane / Street, Road,
Village, Thana, Tehsil, District)
Village:
District:

3.

PIN

Home Address in full


(i.e. House No. Lane / Street, Road,
Village, Thana, Tehsil, District)
Village
District:

4.

Father's details:
(a) Name in full with aliases, if any

(a)

(b) Present postal address

(b)

(c) Permanent Home Address

(c)

(d) Profession
(e) If in service give designation & Official
Address

(d)
(e)

(if dead, give last address)

5.

6.
7.

(i) Nationality of: (a) Father


(b) Mother
(c) Husband
(d) Wife
(ii) Place of birth of:
(a) Husband
(b) Wife
(a) Exact date of birth (DD/MM/YYYY)
(b) Present age as on 01.01.2012
(c) Age at matriculation
(a) Place of birth, District & State in
which it is situated

(b) District & State to which you belong.


8.

(a) State your Religion

(b) Are you a member of a Scheduled Caste /


Scheduled Tribe? Answer 'Yes' or 'No'' and if
the answer is 'Yes' state the name thereof.

PIN

(a)
(b)
(c)
(d)
(a)
(b)
(a)
(b)
Years
(c)
(a)Place of Birth:

Months

Days

District:
State:
(b) District:
State:
(a)
(b)

Continued...2

-29. If you have, at any time been employed, give details:


Designation of Post held or description of
If you have, at any time been employed give details: work.
Period
Full address of the Office, Firm or
Institution.
From
To

10. Have you ever been convicted by a Court or any Officer? If the answer is 'Yes' the full particulars of the
convictions & the sentences should be given.
11. Name of two responsible persons of your locality or two references to whom/you are known.
(1)
(2)

I certify that foregoing information is correct and complete to the best of my knowledge and belief, I am not
aware of any circumstances which might impair my fitness for employment under Government.

Signature of candidate
............................ Date
........................................................
Place .......................................................

(Certificate to be singed by a Gazetted Officer or Member of Legislative Assemble or other authority


prescribed by the Appointing Authority)
Certified
that
I
have
known
Shri/Smt./Kumari...................................................................
S/o/Wife/Daughter of Shri ..................................................for the last ...................years/months and that to
the best of knowledge and belief the particulars furnished by him/her are correct.
Place
Date

.........................
.........................
Signature..........................................................................
Designation or Status & Address......................................
...........................................................................................
Rubber Stamp....................................................................

layXud&4
fu;qfDr ds fy, v;ksX;rk %&
1 fdlh Hkh ,sls iq:"k mEehnokj dks ftldh ,d ls vf/kd thfor iRuh gks fu;qfDr ds fy, ik= ugha ekuk
tk,xkA fdlh vH;FkhZ dks bl fu;e dh dk;Zokgh ls NwV nh tk ldrh gS ;fn ljdkj larq"V gks fd ,slk
djus ds fy, fo'ks"k vk/kkj gSA
2 fdlh Hkh ,slh efgyk mEehnokj dks] ftlus ml iq#"k ls fookg fd;k gS ftlds igys thfor iRuh gS] fu;qfDr
ds fy, ik= ugha ekuk tk,xkA fdlh efgyk vH;FkhZ dks bl fu;e dh dk;Zokgh ls NwV nh tk ldrh gS ;fn
ljdkj larq"V gks fd ,slk djus ds fy, fo'ks"k vk/kkj gSA
3 fdlh Hkh fookfgr iq#"k@efgyk vH;FkhZ dks fu;qfDr ds fy, ik= ugha ekuk tk,xk] ;fn mlus vius fookg ds
le; ngst Lohdkj fd;k gksxkA
Li"Vhdj.k%& bl fu;e ds iz;kstu gsrq ^^ngst^^ ls ;gh rkRi;Z gksxk tks ngst izfr"ks/k ,DV] 1961 esa gS
lSUVy ,DV] 28 vkWQ 1961A
4 ,slk dksbZ Hkh vH;FkhZ] ftlds 1&6&2002 dks ;k mlds i'pkr nks ls vf/kd cPps gkss lsok esa fu;qfDr ds fy,
ik= ugha gksxk%
ijUrq nks ls vf/kd cPpksa okys fdlh Hkh vH;FkhZ dks fu;qfDr ds fy, rc rd fujfgZr ugha le>k tk,xk] tc
rd fd 1 twu] 2002 dks fo|eku mlds cPpksa dh la[;k esa c<+ksRrjh ugha gksrh %
ijUrq ;g vkSj fd tgka fdlh vH;FkhZ ds iwoZrj izlo ls dsoy ,d cPpk gS fdUrq fdlh ,d i'pkr~orhZ
izlo ls ,d ls vf/kd cPps iSnk gksrs gaS ogkW cPpkas dh dqy la[;k dh x.kuk djrs le; bl izdkj iSnk gq,
cPpksa dks ,d bdkbZ le>k tk,xkA
ijUrq ;g Hkh fd fdlh vH;FkhZ dh larkuksa dh dqy la[;k dh x.kuk djrs le; ,slh larku dh] tks iwoZrj
izlo ls iSnk gqbZ gks vkSj fu%'k gks] x.kuk ugha dh tk,xhA
5 'kklu ds ifji= ekad i-619 x`g&13@2006 fnukad 22&5&2006 ds vuqlkj bl ifji= ds tkjh gksus dh
fnukad ls jktdh; lsok esa fu;qfDr gsrq fookg iath;u djk;k tkuk vfuok;Z fd;k x;k gSA
6 foHkkx }kjk fdlh Hkh ijh{kk esa fooftZr (Debar) fd;s x;s ,sls vkosnd ftuds fooftZr (Debar) gksus dh
vof/k vkosnu i= izkfIr dh vfUre fnukad rd lekIr ugha gqbZ gS] bl ijh{kk gsrq vkosnu ugha djsaA
7 izR;sd izkFkhZ dk 'kkjhfjd ,oa ekufld :i ls LoLFk gksuk vko';d gS vkSj mls fdlh izdkj dh fpfdRldh;
ijh{k.k gsrq rRij jguk gksxk tks fd fu;qfDr djus okyk vf/kdkjh mfpr le>asA
8 fdlh vkijkf/kd izdj.k esa nks"kfl) gksus ;k U;kf;d :i ls fopkjk/khu gksus ij fu;qfDr gsrq vik= gks ldrk
gSA
9 ;fn dksbZ vkosnd tkucw> dj vlR; ckr fy[ksxk ;k dksbZ rF;iw.kZ ckr fNik,xk] rks mls vik= ?kksf"kr
djrs gq, n.MkRed dk;Zokgh dh tk,xhA

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&% izek.k i= laca/kh funsZ'k %&


vkosnd dks oxZ fo'ks"k foks"k ;ksX;tu@fu%'kDrtu@jktLFkku jkT; ds vuqlwfpr tkfr@vuqlwfpr tutkfr@fiNM+k
oxZ@foks"k fiNM+k oxZ@ vkfn dk ykHk dfri; 'krksaZ ds vUrxZr ns; gksrk gSA blds izek.k esa vkosnd dks
izek.k&i= ijh{kk dk ifj.kke ?kksf"kr fd, tkus ds mijkUr foLr`r vkosnu&i= ds lkFk ekaxs x;s gSaA
1- tkfr izek.k&i= o ewy&fuokl izek.k&i= %&
1. foks"k ;ksX;tu fu%'kDrtu ds vfrfjDr vU; vkjf{kr Js.kh dk ykHk dsoy jktLFkku jkT; dh ewy fuoklh
dks fn;k tkrk gS] vU; vH;FkhZ lkekU; oxZ ds varxZr vkosnu djsaA
2. ;fn fdlh vU; jkT; dh efgyk vH;FkhZ fookgksijkUr jktLFkku jkT; dh ewy fuoklh cu pqdh gS vkSj og
vkjf{kr Js.kh esa vkrh gS] rks mls jktLFkku jkT; ds ewy fuokl ds vfrfjDr ;g Hkh lk{; izRrqr djuk gksxk
fd mldh tkfr nksuksa jkT;ksa esa leku :i ls vkjf{kr Js.kh esa vkrh gSA ;fn mlds fookgiwoZ ;k tUe ds ewy
jkT; esa mldh tkfr vkjf{kr Js.kh esa ugha Fkh] rks mls vkj{k.k dk ykHk izkIr ugha gksxkA
3. fookfgr efgyk vH;FkhZ dks muds firk ds uke ls tkjh tkfr izek.k&i= /kkfjr djuk vko;d gS] vU;Fkk
mls bl oxZ dk ykHk ns; ugha gksxkA pwafd fdlh vH;FkhZ dh tkfr fookg dh ctk, iSr`d :i ls fu/kkZfjr
gksrh gS] vr% ifr ds uke ls tkjh tkfr izek.k&i= ekU; ugha gSA
4. jktLFkku jkT; ds fiNM+k oxZ@foks"k fiNM+k oxZ ds hehys;j ds vH;fFkZ;ksa dks vkj{k.k dk ykHk ns; ugha gS]
vr% ,sls vH;fFkZ;ksa dks Online Application Form ij lkekU; vH;FkhZ ds :i esa vkosnu djuk gksxkA tks
vH;FkhZ fiNM+k oxZ@foks"k fiNM+k oxZ esa ukWu&hehys;j ds varxZr vkrs gSa] os Hkh /;ku nsa fd mudk
izek.ki=&
o uohure gks vkSj vkosnu dh vafre frfFk dks vH;FkhZ ml oxZ esa vkrk gksA
o fu;ekuqlkj firk@ekrk dh vk; ds vk/kkj ij tkjh gksA
o l{ke vf/kdkjh }kjk fu/kkZfjr izi= ij tkjh fd;k gqvk gksA
5. ;fn vH;FkhZ tutkfr mi;kstuk {ks= Vh-,l-ih- {ks= dh vuqlwfpr tkfr o vuqlwfpr tutkfr ls lacaf/kr gS]
rks ;g lqfuf'pr dj ys fd oLrqr% og blh {ks= dk ewy fuoklh gSA lqyHk lanHkkZFkZ bl {ks= esa ifjxf.kr gksus
okyh jktLFkku dh iapk;r lfefr;ksa o xzke iapk;rksa dh lwph layXu gSA bls vH;FkhZ jkT; ljdkj dh
uohure vf/klwpuk ls viMsV dj ysaA

jktLFkku esa tutkfr mi;kstuk {ks=


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vkSj ihify;k xzke
2- cqtjk iapk;r ds cqtjk] u;k xjgk] iksiYrh vkSj u;k [ksMk xzke
3- ubZ iapk;r dk ubZ xzke
4- MksMkoyh iapk;r ds MksMkoyh] dkyhokl] djukyh] lqjkuk] cksjkckjk dk [ksMk]
eknjh] cNj vkSj dsyh xzke
5- cMh manjh iapk;r ds cMh manjh] NksVh manjh] ihiyokl vkSj dqekfj;k [ksjokxzke
6- vylhx<+ iapk;r ds vylhx<+] ibZ vkSj vkj xzke
7- iMwuk iapk;r ds iMwuk] vejiqjk vkSj Tokyk xzke
8- pukoMk iapk;r dk pukoMk xzke
9- lk# iapk;r ds lk# vkSj cju xzke
10- rhjh iapk;r ds rhjh] cksfjdqvk vkSj xksft;k xzke
11- tkoj iapk;r ds tkoj] jkou] /kkojh rykbZ] u;k [ksMk] dkuiqj vkSj mn;[ksMk
xzke
12- ckjkiky iapk;r ds ckjkiky] rksjkuk] rkykc vkSj dkfn;k [ksr xzke
13- dk;k iapk;r ds dk;k vkSj pkUnuh xzke
14- rhrkjnh iapk;r ds rhrjnh] Qkank] fcfy;k] ndudksVjk] <ksfy;k dh ifV~V vkSj
lchuk[ksMk xzke
15- dkuiqj iapk;r dk dkuiqj xzke
16- cyh iapk;r ds cyh] cwansy] ykyiqjk] ijkoky] [ksjh vkSj tliqjk xzke
17- pUnlk iapk;r ds pUnlk] nekjksa dk xqMk] ekenso] >kaejdksVMk] lkFkiqjk xqtkju]
lkFkiqjk ehuku] tkyh dk xqjnk] [kjck] ekuiqjk vkSj tks/kiqfj;k xzke
18- txr iapk;r dk txr xzke
19- nrhlj iapk;r ds nrhlj] #uht] clw] vkSj jksM~Mk xzke
20- ydM+okl iapk;r ds ydM+okl vkSj ijksyk xzke
21- Hkkyk dk xqjgk iapk;r ds Hkkyk dk xqjgk] dkjxsV] Hksalkgnk vkSj fcjNhxzke

tks vkosnd jktLFkku dh fdlh vuqlwfpr tkfr@vuqlwfpr tutkfr@fiNM+k oxZ@foks"k fiNM+k oxZ ds gksa]
mUgsa pkfg, fd os blds izek.k Lo:i fu/kkZfjr izi= esa fuEu vf/kdkfj;ksa esa ls fdlh ,d vf/kdkjh }kjk
iznRr izek.k&i= izLrqr djsa& tks fd vkosnu i= izkfIr dh vfUre fnukad ds iwoZ vkSj uohure tkjh gks&

i. District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/ Additional Deputy


Commissioner/ Deputy Collector/Ist Class Stipendiary Magistrate/ City Magistrate/ Sub-Divisional
Magistrate/ Taluka Magistrate/ Executive Magistrate/Extra Assistant Commissioner. (not below the
rank of Ist Class Stipendiary Magistrate).
ii. Chief presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate.
iii. Revenue Officer not below the rank of Tehsildar.
iv. Sub-Divisional Officer of the area where the candidate and/or his family normally resides.
v. Administrator/Secretary to Administrator/ Development Officers (Lakshadeep Island).
fu%'kDrrk izek.k&i=%& ;fn vkosnd fu%'kDr O;fDr Disabled Person dh Js.kh esa vkrk gS] og blds izek.k esa
jktLFkku ljdkj +}kjk izkf/kd`r fpfdRlkf/kdkjh }kjk iznRr 40% ;k blls vf/kd fu%kDrrk dk izek.k&i= gksuk

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fu%'kDrrk Js.kh
fu%'kDrrk miJs.kh

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pkfg, vkSj ;fn rykd'kqnk gSa rks Hkh bl lEcU/k esa izek.k gksuk pkfg,A ;fn vkosnd dk fookg jktLFkku jkT; ds
ckgj lEiUu gksus ds dkj.k iathd`r ugha gqvk gS ;k vfuok;Z fookg iath;u ykxw gksus ls iwoZ lEiUu gksus ds
dkj.k iathdj.k ls NwV pkgrk gS] rc Hkh og bl gsrq iw.kZ fooj.k lfgr mldk 'kiFki= gksuk pkfg,A
3

5- vk;q dk izek.k&i=%& vk;ksx }kjk gkbZ Ldwy@lSd.Mjh@gk;j lSd.Mjh ds izek.k&i= esa vafdr tUe fnukad
dks gh Lohdkj fd;k tkrk gSA

6- lsokjr vH;FkhZx.k gsrq vukifRr izek.k&i= & vH;FkhZ ;fn ljdkjh ukSdjh esa gksa ;k ljdkjh vkS|ksfxd

mieksa esa gksa rks os vius foHkkxk/;{k@dk;kZy;k/;{k ls vukifRr dk izek.k&i= No Objection Certificate izLrqr
djsa A
7- ,u-lh-lh- izf'k{kd o izf'kf{kr vH;FkhZx.k gsrq izek.k&i=%& dfri; lsokvksa esa ,u-lh-lh- dSMsV izf'k{kd
bULVDVlZ dks vf/kdre vk;q lhek esa NwV nh tkrh gSA dfri; lsokvksa esa ,u-lh-lh- o izf'kf{kr vH;FkhZx.k
ojh;rk dk izko/kku gS ftlesa ;ksX;rk/kkjd dks lh&lfVZfQdsV /kkjd gksuk vko';d gSA

uksV% ;g lkekU; funsZk gSa] fdlh Hkh fcUnq ij vfUre fu.kZ; vf/kfu;e]@fu;eksa esa nh xbZ O;oLFkkvksa ds
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