CHECK LIST FOR CERTIFICATE VERIFICATION - DSC 2012 - MEDAK DISTRICT

(To be filled by the Candidate with own Hand Writing)

Candidate ID No Category of the POST (Subject) Rank Hall Ticket No Medium Total Marks (TET+DSC)

Applicant Name : Father's Name : Date Of Birth : Gender (M/F) :

Address For Communication :

Mandal : District : Pin Code :

Native District You Belongs to : Community(Caste) You Belongs to :

Mobile No :
Do you belong to Andhra Pradesh State (Yes/No) : Are you an Ex-Service Man (Yes/No) : Are you a Physically Handicapped(PH) Person (Yes/No) If Yes mention the PHC Category (OH/VH/HI) Percentage of Handicapped Whether the PHC Certificate issued by the Referral Hospital concerned after 30.01.2012 as per GO Ms.No.91, Edn, Dt:03.11.2012) (Yes/No) Type of study (Regular/Private) ( IV to X Class Only)

BASIC EDUCATIONAL DETAILS (studied/Resided District)

Class Period of Study Name of the School Name of the Mandal Name of the District State

4th 5th 6th 7th 8th 9th 10th

Local District You Belong to

(as per Study)

EDUCATIONAL QUALIFICATIONS
1. SSC or its Equivalent Qualification
Board Medium 1st Language Date of Passing

2. Intermediate or its Equivalent Qualification:

Board Medium 2nd Language Date of Passing

3. Degree or its Equivalent Qualification:

PassingDate of 2nd Language 2nd Optional Subject 3rd Optional Subject 1st Language Qualification Type of Study (Regular/Dis tance) 4th Optional Subject 1st Optional Subject University Medium

4. Post Graduation or its Equivalent Qualification:

Qualification Subject University Date of Passing

Applied Post Details :

Applied for the post (SA/SGT/LP /PET)
1) 2) 3)

Post Subject

Post Medium

Hall Ticket No

Total Marks Secured (TET+DSC)

Rank

Whether you are Selected in Provisional List (Yes/No)

If you have Selected in More than One Post, Which Posts you are preferring

Professional Qualification(s) Details :

Name of the Course D.Ed Pandit Training B.Ed I here by declare that the particulars given in this Application are true to the best of my knowledge and belief. Certificates furnished for verification are Original and belongs to me Only. I also fully understand that if any of the above mentioned particulars are found incorrect, later on, at any stage, my candidature would be rejected and in case of my securing the employment, the services would be terminated. If any deviation is found at any time I am liable for any action by the competent authority as per rules. Name of the University/Board Academic Year Method 1 N/A N/A Method 2 N/A N/A Method 3 N/A N/A Date of Passing

Date : Place :

Signature of the Candidate Name :

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FOR OFFICE USE ONLY

Certified that the Original Certificates of the candidates produced above are verified by me and found correct and the doubts raised by me are recorded specifically.

Remarks: 1)
2) 3)

Signature of the Verifying Officer-1 With Name & Designation

Signature of the Verifying Officer-2 With Name & Designation

Signature of the Verifying Officer-3 With Name & Designation