Roll No.

DETAILED APPLICATION FORM

PERSONAL Affix your Photograph

Name : ( In Block Capitals ) : _________________________________

Date of Birth : ______________________ Age _________________________________

Place of Birth : _____________________________________________________________

Village District State

Contact Address : _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Telephone - Landline : _______________________________________________

Mobile Number_______________________________________________
Alternate Number (if any) :_______________________________________________
Email Address :_______________________________________________

Name of Father
Fathers Profession
District to which father originally Belongs

Name of Mother :
Mothers Profession
District to which mother originally Belongs

Mother Tongue : _______________________________ Marital Status _________________

State whether you

are an SC / ST/ BC : _____________________________________________________________

If ‘Yes’ for BC mention Creamy layer or non Creamy layer: ______________________________________

(Certificate of non creamy layer to be produced)
ACADEMIC RECORD:

Examination Year (s) School / College

Passed From To Name Place/ Dist. Board / Percentage Division Subjects
State University
10th or
Equivalent
Inter or 12th
or
equivalent
Stream at
Graduation
Level
P.Grad.
Others

WORK EXPERIENCE

Position Permanent / Period No. of Years Name of the Employer

Held Temporary and Months

If you were employed briefly mention your responsibilities in the positions held
by you
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
EXAMINATION

Language Medium in which you have written the Examination: _____________________________

Have you appeared at any other competitive examinations for any Government Service?
Mention the details

Year of Name of the examination Were you Recommended for

Exam Appointment
( Mention Rank
and Service )

Mention your Order of Preference of Services

NAME OF SERVICE / POST Order of Preference

Achievements / Prizes / Extra Curricular Activities

1. Mention details of Academic medals, Prizes and Scholarships won by you at School/College/etc.
Specify in case you have participated at the University/State/National Level
_______________________________________________________________________________
_______________________________________________________________________________
2. Have you participated in any Sports/ NCC/ NSS? If Yes, mention the details below
_______________________________________________________________________________
_______________________________________________________________________________
3. Have you held any positions of Distinction/Leadership at School /College/Voluntary organization. If
Yes, mention the details below
_______________________________________________________________________________
_______________________________________________________________________________
4. Mention any other extra curricular activities and interests (such as Hobbies etc.)
_______________________________________________________________________________
_______________________________________________________________________________
5. Have you participated in any social service activity where you displayed compassion for the
underprivileged? Briefly describe the activity.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Signature_________________________ Date____________________ Place ________________