APPLICATION FORMAT For the post of Revenue Inspector (To be filled up in BLOCK letter) 1. 2. 3. 4.

Name of the Applicant (in full) Name of the Father/ Husband Name of the Post applied for Permanent Address : : : :

5. Present postal address for correspondence. ATPOPSDIST6. Nationality : 7. Religion : 8. Date of Birth in Christian era : Day Month Year (as recorded in HSC) 9. Age as on 01.01.2012 Year Month Days 10. Category (SC/ST/SEBC/UR) : (PH/Ex-Servicemen/Sportsperson) 11. Male/Female : 12. Marital Status : 13. Valid Registration No & Name of the Employment Exchange : 14. Educational Qualification : Sl. Name of the Year of Name of Subject Full Marks %of No. Examination Passing the Board/ Marks Secured mark passed University Secured

15. Whether able to speak, read & write Odia (yes/No) : 16. Whether passed the H.S.C or equivalent exam having Odia as a subject (Yes/No) : 17. Details of Bank Draft submitted : (iii) Bank Draft No. Amount (iv) Name of the issuing branch Date of issue 18. List of enclosures : DECLARATION I Sri/Smt./Ms. Do hereby declares that the information furnished above is true, complete and correct to best of my knowledge and belief. In the event of any information being found false or incorrect at any stage my candidature/selection/appointment is liable to be cancelled/terminated without any notice by the authority. Place Date (Full Signature of the Applicant)