Application form Part A

Advertisement No. 24900 dated 07/12/2016

Application form No …………. (for office use only)

Application form Part A (On Contract / On Deputation)

Recent coloured P.P. size photo graph attested by self

1. Name of the post (Applied for) : ………………………………………………… 2. Post code no. : ………………. (i.e. s. no. of post in advertisement) 3. Name of applicant :. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name)

4. Father's name

(Surname)

: ……………………………………………………………… (Name)

5. Permanent address

(Surname)

: ……………………………………………………………… ………………………………………………PIN………….

6. Present address

: ……………………………………………………………… ………………………………………………PIN………….:. (Address proof : Enclosure 1)

7. Date of birth

:. . . . /. . ../ . . . . . . . (In words …….. . . . . . . . . . . . . . . . . . . . .)

(Attested true copy of marksheet of Higher Secondary School Certificate Examination /equivalent examination exhibiting date of birth : Enclosure 2) 8. Age as on the date of Advertisement : …………… Years ………… Months …………. Days 9. Category (Please tick)

: Unreserved/ OBC/ SC/ ST

(Self attested true copy of caste certificate in case of OBC/SC/ST candidate : Enclosure ….3) 10. Home district

: ………………………………………………………………

11. Educational qualification details : (1) Post Graduation

: Degree . . . . . .. .. . Specialisation in ……………………….

(2) Graduation

: Degree . . .. . . .. . . .Subject …………………………………

(3) Others (Diploma etc.)

: Description ……… . .. . .. . . . . . . . . . . .…………………….

12. Service and experience details : (a) Parent Department : ………………………………………………………………. (b)

Details of organization : ……………………………………………………………….

(c)

If working, then, present Post :. ……………………………………………………………. 1

(d)

If retired, then, name of the post from which retired :……………………………………….

(e) If working then address of the present office:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . ….... (f) (g)

Designation at first posting :. . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ………………. If working, then present pay :. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ….. (As per present applicable pay rules) (e.g. pay in the pay band and grade pay in revised pay structure)

(h)

If retired, then last pay details

: . . . . . . .. . . . . . . . . . . . . . . . . . . . . ……………….

(i)

Present basic pay :. Rs. . . . . . .. . . . . . . . . . . . . . . . . . . . . (e.g. pay in pay band + grade pay, in revised pay structure)

(j) S.N.

Post wise experience (as on date of publication of advertisement) Name of Post

from date …………to date ……….…

field work experience Years . . . . . Months . . . Days……

office work experience Years . . . . . Months . . . Days……

1 2 3 4

(k)

Total length of service (as on date of publication of advertisement) :.. . . . . ..Years . . . . .Months . . . . . Days.

(l) Total length of service (as on date of publication of advertisement) :.. . . . . ..Years . . . . .Months . . . . . Days. 12. PAN (if available) (Attested true copy: Enclosure . . . . )

: ……………………………………..

13. Cell phone no.

: ……………………………………..

14. Email ID

: ……………………………………..

(Signature of applicant) Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . . 2

Declaration I hereby declare that no criminal proceedings of any nature is pending against me. I further declare that information supplied by me in, the application form and its supplementary parts and enclosures annexed to it; are true to the best of my knowledge & belief. My selection to the post may be cancelled and suitable action may be taken, if information furnished by me in part A, B, C and D is found false or incorrect at any point of time in future. (Signature)

Date :. . . . . . .. . Place :. . . . . . .. .

Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . .

Encl – Part B,C and D of the application along with enclosure 1 to ……….

3



Part B (On Contract / On deputation)

1. Name of the post (Applied for) : ………………………………………………………………. 2. Post code no. : ………………. (i.e. s. no. of post in advertisement) 3. Name of applicant

:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . (Name)

4. Father's name

(Surname)

: ……………………………………………………………… (Name)

5. Present address

(Surname)

: ……………………………………………………………… ………………………………………………PIN………….:. (Address proof : Enclosure 1)

6. Date of birth

:. . . . /. . ../ . . . . . . . (In words …….. . . . . . . . . . . . . . . . . . . . .)

(Self attested copy of mark sheet of Higher Secondary School Certificate Examination /equivalent examination exhibiting date of birth : Enclosure 2) 7. Age as on date of advertisement : …………… Years ………… Months …………. Days 8. Category (Please tick)

: Unreserved / OBC / SC / ST

(Self attested copy of caste certificate in case of OBC/SC/ST candidate : Enclosure …..) 9. Home district

: ………………………………………………………………

10. PAN (if available)

: ………………….

(Attested true copy : Enclosure . . . .)

(Signature of applicant) Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . .

4



Part C (On Contract / On deputation)

1. Name of the post (Applied for) : ……………………………………………………………… 2. Post code no. : ………………. (i.e. s. no. of post in advertisement) 3. Name of applicant

:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . (Name)

4. Father's name

(Surname)

: ……………………………………………………………… (Name)

(Surname)

5. Educational qualification details : (1) Post Graduation

: (i)Degree . .. . ..

. .. . . Specialisation in ……………

: (ii) Name of institution : (iii) Year of passing : (iv) Percentage of marks/CGPA (Enclosure…….) (2) Graduation

: (i)

Degree . .. . . .. . . .. Branch ………………………

: (ii) Name of institution : (iii) Year of passing : (iv) Percentage of marks/CGPA (Enclosure…….) (3) Others (Diploma etc.) : (i)

Description …………………………

: (ii) Name of institution : (iii) Year of passing : (iv) Percentage of marks/CGPA (Enclosure…....) (Signature of applicant) Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . .

5

Advertisement No. 24900


Part D

dated 07/12/2016 (On Contract / On deputation)

1. Name of the post (Applied for) : ……………………………………………………………… 2. Post code no. : ………………. (i.e. s. no. of post in advertisement) 3. Name of applicant

:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . (Name)

4. Father's name

(Surname)

: ……………………………………………………………… (Name)

(Surname)

5. Postwise Service and experience details : S. No.

Designation

length of service from date ……….. to date …………

field work office work Total experience experience Years . . . . . Years . . . . . Years . . . . . Months . . . Months . . . Months . . . Days…… Days…… Days……

Brief description of work

1

2

3

6. Field experience on present post (as on date of publication of advertisement :. ….. . . Years . . . . .Months . . . Days. 7. Total length of service (as on date of publication of advertisement) :. . . . . . ..Years . . . . .Months . . . . . Days. 8. Name of authority, competent to provide NOC and its address : …………………………….. ………..………………………………………………………………………………………….. 9. Whether NOC has been enclosed or not ? : …………………………………………………. (For deputation only) 10. Details of any two construction works which you would like to mention Designation

Period from date ………. to date ……...

Details of work

Approx cost of executed work

executed

in Rs .Lakhs

(Signature of applicant) Name of the Applicant: . . . . . . .. . . . . . . . . . . . . . . . .