HARYANA PUBLIC SERVICE COMMISSION

Advertisement, Post & ChallanDetails For Office Use Only

Advertisement No. : 1 Space for Marking

: Naib Tehsildar {(Apprentices)
Name of Post
Gazetted Class-II (Group-B)
Registration No. : 2118106767
Challan Detail
Journal No. :
Amount : 125
Bank Name : State Bank of India Signature of Marking Officer

Candidate Particulars :
1 Candidate Name : SEEMA
2 Father's Name : KRISHAN
3 Mother's Name : LAKHPATI
4 Date of Birth : 02/07/1993
5 Age as per Advt. : 24 Years 5 Months 30 Days
Correspondence Address :
6 Address : VPO BEHLBA TEHSIL MEHAM
ROHTAK Haryana-124120
Please fix the
Permanant Address : Original Photo
before submitting
7 Address : VPO BEHLBA TEHSIL MEHAM
to the HPSC
ROHTAK Haryana-124120

Personal Details :
8 Have you passed Hindi/Sanskrit upto Matriculation : Yes
9 Nationality : Indian
10 Gender : Female
11 Marital Status : Married
:
12 Are you domicile of Haryana ? : Yes
13 Have you ever been debarred by UPSC/HPSC/OTHERS State PSC or : No -
any other Govt. Dept. ?
Have you ever been convicted by Criminical court ? : No -
Are you employed in Govt/Public sector undertaking?(If yes and you : No
14 are in regularar service then give details and have to submit NOC from
the employer at the time of interview).

Contact Details :
15 Contact Number : 9812290027
16 EmailID : SHARMA.SEEMA015@GMAIL.COM
Extra-Co-Curricular Activities :
17 Extra-co-curricular/sports activities :
18 NCC, NSS, cultural activities :

Category Detail For The Post:

19 Post Claim Category : General
20 Fee Claim Category : Female Candidates
21 Age Claim Category : General
Candidate Bank Detail:
22 Bank Name : SARVA HARYANA GRAMIN BANK
23 Bank Number : 82160100020372
24 Bank Branch : LAKHAN MAJRA
25 IFSC code : PUNB0HGB001
26. Qualification Details :
Qual. Passing Marks Total
Examination Board/University Subjects % Div
Name Year Obtain Marks
HIN ENG MATH SCI
Matriculation 10TH HBSE BHIWANI 2008 360 500 72.00 1
SKT SS
12TH VAISH TECHNICAL
Intermediate ALL 2011 4750 7250 65.52 1
DIPLOMA INSTITUTE ROHTAK
SAT PRIYA GROUP
Graduation B.TECH OF INSTITUTE ALL 2014 4691 6100 76.90 1
(MDU)
SAT PRIYA GROUP
Post Graduati M.TECH OF INSTITUTE ALL 2016 2456 3050 80.52 1
(MDU)
27. Experience Details :
Organization Designation From Date To Date Total Exp. Nature of Duty Salary/M
TECHNOVITE LAB PROJECT
TEAM MEMBER 03/02/2014 02/06/2014 0Y-3M-29D
PVT. LTD ASSIGNED

Declaration :
(To be signed by the candidate)
I. All statements made in this application form are true, complete and correct to the best of my knowledge
and belief. In the event of any information being found false or incorrect, or ineligibility being detected
before or after the examination (Preliminary, Main or on selection), my candidature may be cancelled and
action can be taken against me by the Commission.
II. I have read the advertisement, instructions to candidates and provisions in the Brochure of the
Commission related to this examination carefully and I hereby undertake to abide by them. I fulfill all the
conditions of eligibility regarding age limit, educational qualifications etc. prescribed for admission to the
examination in the advertisement, instructions for candidates, provision of Brochure and other relevant rules
and instructions.

Candidate Signature
SEEMA
Name in capital letters

Place :
Date : 14/05/2018 [ Signature of the Candidate ]
(Before submitting the form to HPSC)

Note : Incomplete and unsigned application form shall be rejected.