(‘Navratna’ - Government of India Enterprise)

RECRUITMENT CELL / HR DEPARTMENT / CORPORATE OFFICE

Block-1, Neyveli-607 801, Cuddalore District, Tamil Nadu
Affix recently taken
color passport size
APPLICATION FORM
photograph & the
same to be self
attested
Post Applied: SME Operator on Fixed Term Employment basis for a period of 2 Years
Pay & Grade : INR.38,000/- (F5- W Grade)

Advt. No. : 04/2021

(FILL IN CAPITAL LETTERS)
1. Name in full:

2. Father’s Name:

3. Communication Address of the applicant

Description (a) Permanent (b) Present

House No,

Street Name,

Area / Locality,

City/Town/Village,

Taluk/ Mandal
District
State
Pincode
Contact Number

(c) e mail :

D D M M Y Y Y Y
4. Date of Birth :

Age as on 01-06-2021 : _____Years _____ Months _____ Days

SC ST OBC UR EWS
5. (a) Community :

(b) Sub-Caste :

(c) Religion :

(d) Nationality :
By Birth / Domicile

(e) Place of birth :

State :
(f) Hometown :
 Yes No
(g) Whether Project affected Person :

If Yes, details of the Project affected person :

6. If belonging to the following Special categories, details:

Category Yes / No Details

Ex-Serviceman

7. Educational / Professional Qualification(s)(Use additional sheets, if required)

Name of the Course Year of Duration of the Name of the Board / Institute / % of Marks /
Passing Course University Class or
Grade
ITI

SSLC (10th Standard)

HSC (12th Standard) /

PUC

8. Details of Experience
Name of the Institution / Period of Employment Designation & Nature of Pay Details
Organisation From To duties
(Last employment first). (DD/MM/YY) (DD/MM/YY)

9. Whether presently working in any PSE / YES NO

Govt. / Quasi Govt. Organisation?
10. Marital Status (Please put mark) : Married / Single / Widower / Widow

11. Are you a former employee of NLCIL? : YES NO

If Yes, details

CPF No.

Unit

Years of service

Date of Relief

12. Have you been a candidate for any other post in YES NO
NLCIL before?

If so, furnish details.

13. a) Have you ever been convicted / detained / prosecuted / YES NO

arrested / bound down / debarred/ fined by Court of law?
If so furnish details.
YES NO

b) Is any case pending against you?

If yes, give details.

15. References: Please furnish below names of two persons not related to you, to whom reference could
be made regarding your character and antecedents.
(i) Name (ii) Name

Position Position

Address Address

Tel. No. Tel. No.

Mobile Mobile

I hereby declare that all the above information’s furnished by me are true and complete. I am aware that
furnishing of false / incomplete information’s will result in rejection of my candidature / loss of employment, if
appointed to the post applied, at any stage.

Place:
Date:
Signature of the Applicant