! No CABINET SE CRE TARIAT the form in E: h capital Affix self attested recent Advt. No. -06/13 Post applied for (Tick ‘ V’ against relevant post) Basset vies SSE photograph 1. Name 2. Address for correspondence : | (Please mention PIN Code and name of STATE clearly.) PIN stare] | | Lt 3. Contact No. (Mobile / Landline) a T THI 4. Father's Name E | 5. Date & Place of Birth Date ‘Month Year |1|9 Place |. 1 6. Age as on closing date (0708-2644) ‘Months Days, Ciyjfor fr 4) | 7. Code for Category (Refer note 1D A 8. Ifex-serviceman, please indicate’ 5 | Length of Service sites Dave ii) Date of joining _ iii) Date of discharge (enclose copy of discharge certificate) 9. Sex 10. Nationality 11. Religion 12. Marital Status Ifmarried, a) Religion of spouse b) Nationality of spouse Contd...£-=f 13. Educational Qualifications ' Aggregate Exam / Year of | Duration of the "i University/Board Subjects Studied | marks with Degree passed Passing | Degree / Diploma percentage | i 14, Whether employed or not ql 15. Ifyes, Details of Employment in Chronological order:- @ ‘Adchoo | Bxact date to be x i fice! MRegular given lature of Institute / Organisation | Post Held | Seale of Pay |“ duties From | To 16. Computer Knowledge, if any 17. Typewriting speed 18. Language Known (Indian/Foreign) = Taseace Read | Write | Speak with proficiency to read, write & speak 19, Examination Centre = Delhi | Mumbai | Kolkata | Chennai | Lucknow | Shillong | Jammu (Tick “against relevant eslumn) | yment reserves the right of final DECLARATION Thereby declare that a) I fulfill the eligibility for the post applied for: b) I have not submitted any other application in response to the same advertisement. In the event of information or part thereof 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. Signature of the applicant Aavps8iet Ai foos 2/1314 Eee