INSURANCE CORPORATION N: C..G. MARG: NEW DELHE-2 (SO 9001:2000 QMS CERTIFIED) RECRUITME TOF SPECIALISTS GRADE-IL(IR. SCALE, \-12/16/6/2010-Exams Date : 03/01/2011 ‘ORRGENDUM The test given in the Original Advertisement at No, 1 in Essential {Qualifications may he read as “Language Test ~ The candidate shall have passed middle level examination in Official Language of the State concerned.” Joint Director (Reet)PLICATION FORM FOR THE POST OF REGION 1. Particulars of the Demand Draft: (a) Amount of fae Re, (b) Name of issuing bank branch () DD.Ne. at ‘Nama (in capital letters) Father's / Husband's Name Affix attested recent passport size photo Date of Birth (in figures) Gn words) (a) Religion (by Nationality 6 Mailing address with e-mail address) and telephone number) Permanent Address (with telephone number) 8. Sex (write 1 for Male 2 for Female) 0) Gf Physically Handicapped Yer (Orthopaedically handicapped) b) Percentage of Disability Signature of the candidate. [No Gi) Whether Ex Servicoman ‘Yee /No 10. Community to which epplicant belongs (Write 1 fr SC 2 for ST 3 for OBC 4 for General 11, Essential educational qualifications and other training course. if any (Attach Annexure, if necessary) Name & University Duration Degree! Subjects Address of Examination Cellege From to Passed Percentage of marks obtainedO2- 12. Date of completion of compulsory Rotating Internship 13. Date of Registration with MCI / SMC / DCT 14. Details of employment (in chronological order) (Attach Annexure, if necessary), Name of the Position(s) Period Natureof Sealeof_ Basic Pay Organization heldandto of, »=— Work done = Pay, please specify whem service and whether Central reporting reasons for Govt /State leaving Govt /Public Sector JAutonomous Body/Private Sector Thereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief T understand that in the event of any information being found false or incorrect at any stage, my candidature/appointment shall be lisble to be cancelled | terminated summarily without notice or any compensation in lieu thereof. I also affirm that No Objection Certificate from the present employer for applying this pest has been applied for'taken. If colected, Iam willing to serve anywhere in India. Place Date Signature of the Candidate