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ON-LINE APPLICATION FOR COMMON WRITTEN EXAM FOR CLERICAL CADRE

20027
Registration # :

2003407013

Full Name :

MOLOY RANJAN ROY

Category :

SC

If Person with Disability :

NO

Type of Disability :

Percentage of Disability :

Do you intend to use the services of a scribe

(only for VI & OC both hands affected by cerebral palsy) ? :

NA

Whether you Children / family members of those who died in 1984 riots? :

NO

Whether you domiciled in Kashmir Division of the State of

J&K during the period 1-1-1980 to 31-12-1989? :

NO

Whether you belong to Religious Minority Community ? :

NO

Religion to which you belong :

Are you an Ex-Serviceman ? :

NO

Are you a disabled Ex-Serviceman (DISXS)? :

NO

Are you a dependent of an Ex-Serviceman killed in action ? :

NO

Have you passed in one of the following Armed Forces Examinations equivalent to
Civil Examination of HSc/Pre-University? :
IAF Education Test for Promotion to rank of Corporal :

NO

Passing Out (Indian Navy) Examination conducted by Boys Training Establishment,

Visakhapatnam :

NO

Are you a matriculate Ex-Servicemen candidate, who has obtained the Indian Army
Special Certificate of Education or corresponding Certificate in the Navy or the Air
NO
Force after having completed not less than 15 years of service in Armed Forces of the
Union? :
Are you seeking relaxation under widow / divorced women / women judicially
Separated from their husbands and who are not re-married? :

NO

Whether Regular Employees of the Union Carbide Factory, Bhopal, retrenched from
service (applicable to Madhya Pradesh state only)? :

NO

Nationality :

INDIA

State/ UT which the Centre of Examination Belongs :

West Bengal

State / UT Code :

45

Centre of Examination :

Kolkata

Centre Code :

218

Application Fee / Intimation Charges details:

Payment Mode:

CBS

Name Of Payee Bank :

Punjab National Bank

Transaction No. :

M128551

Branch Name :

AMTALA

DP Code / Branch Code No :

6095

Deposit Date :

21-09-2011

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Amount :

50

Personal Details :
Date of Birth :

15-02-1990

Age completed as on 01.08.2011 :

21

Gender :

MALE

Husband's Name/Father's Name :

BISWANATH ROY

Mother's Name :

MAYA ROY

Address for Correspondence :

VILL+UTTAR BAGI PO+PS-BISHNUPUR

District

SOUTH TWENTYFOUR PGS

State :

WEST BENGAL

Pin :

743503

Permanent Address :

VILL+UTTAR BAGI PO+PS-BISHNUPUR

District

SOUTH TWENTYFOUR PGS

State :

WEST BENGAL

Pin :

743503

Contact Details :
Email ID :

moloyroy.me@gmail.com

Phone No :

Mobile No :

9903885682

Qualification Details (as on 01.08.2011):

Exam Passed

Subject /Stream

Date of Passing

% of Marks

SSC/Equivalent :

BEN ENG MATH PHY

29-05-2006

72.00

HSC/Equivalent :

SCIENCE

12-05-2008

59.00

Other Details :
Would You like to undergo Pre-Exam Training (SC/ST/Minority Community/ ExServicemen /PWD) :

NO

If Yes, Centre for Training :

-Languages Known

Read

Write

Speak

BENGALI

YES

YES

YES

ENGLISH

YES

YES

YES

HINDI

YES

YES

YES

DECLARATION:
I hereby declare that all 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 untrue or incorrect at any stage or my not satisfying any of the eligibility criteria stipulated, my candidature is liable to be cancelled.

Place:
Date: 22-09-2011

Please retain your Registration No. and Password emailed to you carefully for further reference
NOTE: Please DO NOT SEND application printout to IBPS

Signature of Applicant