Application Registration No : 60001228820 for Combined Graduate Level Examination-2016

1.& 2. Examination Center and Code :

NER-Dibrugarh(5102)

3. Candidate Name :

AYESHA SAIKIA

4. Father's Name :

RAKIB SAIKIA

5. Mother's Name :

AFREEN SAIKIA

6. Date of Birth(dd/mm/yyyy):

09/09/1994

7. Gender :

Female

8. Nationality :

Indian

9. Fee Exemption claimed :

Exemption

10. Category :

General

10.1. Whether Ex-Serviceman? :

No

10.2. If, ExS, Whether seeking reservation? :

10.3. For Ex-Serviceman-Length of Service(in years) :
10.3. Date of discharge :
11. Whether PH :

No

11.1. If yes, indicate code :

12. Whether seeking Age relaxation :

No

12.1. If yes, indicate code :

12.2. Age(as on 01.01.2016) :

21.3

13. Preference for posts :

ADBZJM$WPSLK

14. Are you applying for the posts of Statistical Investigator Gr.II/ Compiler ? : No
14. Do you possess EQ for the posts of Statistical Investigator Grade II/
Compiler? :

No

14. Are you applying for the posts of AAO ? :

No

14. Do you possess EQ for the posts of AAO ? :

No

15. Whether you belong to Religious Minority Communities as per Govt.

Orders ? :

Yes

16. If VH/ Cerebal Palsy candidate, whether scribe is required ? :

No

16.1. If yes, indicate medium :

17. Aadhar Card Number :

18. Qualification Details (Start from Graduation) :

Educational Qualification

Subject

Percentage(%)of Marks

Medium

B.TECH

Others

70.00

English

PETROLEUM

19. Details of Work Experience/Govt. Service rendered :

Name of the Organisation(s)

Designation

Nature of Duty(ies)

Period Of Service
From(mm/yyyy)

Period Of Service
To(mm/yyyy)

Nil

Nil

Nil

Nil

Nil

Contact Details Form :

20. Postal Address :

UPADA APARTMENTS 2 RAJAT KAMAL PATH RG BARUAH ROAD

State :

Assam

Pincode :

781024

21. Permanent Address :

UPADA APARTMENTS 2 RAJAT KAMAL PATH RG BARUAH ROAD

State :

Assam

Pincode :

781024

STD Code :

0361

Phone Number :

2464735

Mobile Number :

8133085778

Email ID :

ayeshadatsme@gmail.com

PHOTOGRAPH AND SIGNATURE :

SCANNED PHOTOGRAPH OF THE CANDIDATE:

SCANNED SIGNATURE OF THE CANDIDATE

DECLARATION:
I hereby declare that all the 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 false or incorrect at any stage or not satisfying the eligibility criteria according to the requirements of the relative
advertisement, my candidature/appointment is liable to be cancelled/terminated. I am willing to serve anywhere in India.
Place:
Date(yyyy-mm-dd) : 2016-03-28
Signature of Candidate