Note: Please fill in the form in English capital letters. Advt. No.

-06/13 Post applied for (Tick against relevant post.) Lower division Clerk Assistant
Affix self-attested recent passport size photograph

1. Name

2. Address for correspondence : (Please mention PIN Code and name of STATE clearly.) STATE 3. Contact No. (Mobile/Landline) :

PIN

4. Fathers Name

5. Date & Place of Birth

Date

Month

Year

Place

6. Age as on closing date (14/02/2014)

Years

Months

Days

7. Code for Category (Refer Note-II)

8. If ex-serviceman, please indicate:i) ii) Length of Service Date of joining : : Years Months Days

iii)

Date of discharge (enclose copy of Discharge Certificate.)

9. Sex 10. Nationality 11. Religion 12. Maritial Status

: : : :

13. Educational Qualifications:Exam / Degree University passed Year of passing Duration of degree Subjects studied Aggregate marks Percentage

14. Whether Employed or not : 15. If yes, Details of employment in chronological order:Exact date to be given Ad-hoc Office/Institute/ Post Held /Regular Organisation FROM TO /Term/Pmt.

Scale of pay

Nature of duties

16. Computer knowledge, if any:

17. Typing speed

: Language Read Write Speak

18. Language Known (Indian/Foregin) With proficiency to read, write & speak

19. Examination Centre

(Tick against relevant column)

Delhi

Mumbai

Kolkata

Chennai

Lucknow

Shillong

Jammu

(Note: The department reserves the right of final allotment of examination centre)

DECLARATION

I hereby declare that a) I fulfill the eligibility for the post applied for; b) I have not submitted any other application in response to same advertisement. In the event of information or part there of being found incorrect at any stage, my candidature / appointment is liable to be cancelled / terminated without any notice to me and action can be taken against me.

PLACE: DATE: SIGNATURE OF APPLICANT