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ON-LINE APPLICATION FOR COMMON WRITTEN EXAM FOR CLERICAL CADRE

35035
Registration # : 2003742089

Full Name :

VIJAY LAXMAN GAJAK OSH

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 :

SC 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: Name Of Payee Bank : Transaction No. : Branch Name : DP Code / Branch Code No : Deposit Date : CBS Bank of Baroda 220911S00246253 Bank of Baroda Thane west 079 22-09-2011 NO NO A Citizen Of India Maharashtra 30 Mumbai 171

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Amount : 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 : 16-09-1990 20 MALE LAXMAN MEERA KAMLA NEHRU NAGAR DHOBHIGHAT NEAR DURGA MATA MANDIR OPP ANNAPURNA KIRANA STORE District State : Pin : Permanent Address : THANE MAHARASHTRA 421001 KAMLA NEHRU NAGAR DHOBHIGHAT NEAR DURGA MATA MANDIR OPP ANNAPURNA KIRANA STORE District State : Pin : Contact Details : Email ID : Phone No : Mobile No : Qualification Details (as on 01.08.2011): Exam Passed SSC/Equivalent : HSC/Equivalent : Others : 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 MARATHI NO -Read YES YES YES Write YES YES YES Speak YES YES YES Subject /Stream ENGLISH COMMERCE DIPLOMO IN COMPUTER Date of Passing 13-03-2008 10-02-2010 30-09-2010 % of Marks 53.69 52.83 79.00 gajakosh_vijay@yahoo.com 9766648936 THANE MAHARASHTRA 421001 50

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: 22-09-2011

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