Application Form

1. Advt. No. : 16/2010

2. Sl. No. : 13
3. Name of the post : T-1(Fitter)
4. Name of the applicant : SIDHARTHA ROUT
(in block capital letters)
5. Father’s Name : Dhananjaya Rout
6. Present Address : AT- Mahatol, Po- Kulakaijanga, Via- Biridi Road,
Dist- Jagatsinghpur, Pin- 754111.
7. Permanent Address : AT- Mahatol, Po- Kulakaijanga, Via- Biridi Road,
Dist- Jagatsinghpur, Pin- 754111.
8. Educational Qualification :
Exam Passed Institution Year of Class/ Main %
/University Passing Division Subject of Marks
grade
HSE BSE, Orissa 2001 Third All Subject 37.47%

ITI (Fitter) Vanuprava ITC, 2006 1St All 85.29%

Jagatsinghpur,
SCTVT & NCVT

9. Technical / Proffessional Qualification : No

10. Experience : No
11. Whether UR/SC/ST/OBC/P.H : No
12. Religion : Hindu
13. Nationality : Indian
14. Sex : Male
15. I.P.O. No. & Date : 81F 966526 & 27, 87E 970972 & 15-12-2010
16. Tel. No. : 9692607624

DECLARATION : I hereby declare that that the information submitted above are true/
correct and based on documents and at any stage of recruitment it is found that information
submitted by me is false or not correct my candidature will be liable to be cancelled.

Place:
Date: Full Signature of the Applicant