Advertisement No. Application form6459 Application form No ………….

dated 18/03/2016 (for office use only)

Part A

(On Contract / On Deputation)

Recent colouredP.P. size photo

graph attested by

1. Name of the post (Applied for) : …………………………………………………self

2. Post code no. : ……………….(i.e. s. no. of post in advertisement)

3. Name of applicant :. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Name) (Surname)

4. Father's name : ………………………………………………………………(Name) (Surname)

5. Permanent address : ………………………………………………………………

………………………………………………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) Officer and address to competent to provide NOC: ……………...................................................................................................................................................……………………............

(c) Designation at first posting :. . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ……………….

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(d) Date of First Posting : ................................................................................................

(e) If working, then, present Post :. ……………………………………………….....…….

(f) Date of posting at present post : .......................................................................................

(g) If working then address of the present office with post :...... . . . . . . . . . . . . . . . . . . . . . …....

(h) 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)

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

(j) If retired, then last pay details : . . . . . . .. . . . . . . . . . . . . . . . . . . . . ……………….

(k) Present basic pay :. Rs. . . . . . .. . . . . . . . . . . . . . . . . . . . .

(e.g. pay in pay band + grade pay, in revised pay structure)

(l) Total length of service (as on date of publication of advertisement)

:. . . . . . Years . . . . .Months . . . . . Days.(m) Post wise details of service for General Manager/Assistant Manager/ Sub Engineer :

S.N.

Post Period from ......... to ..........

Total length of service (in

year)

Total experience in field (in year)

1 As a Sub Engineer

2 As a Assistant Engineer

3 As a Executive Engineer

4 As a Superintend Engineer

13. PAN (if available) : ……………………………………..

(Attested true copy: Enclosure . . . . )

14. Cell phone no. : ……………………………………..

15. 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.

Date :. . . . . . .. .

Place :. . . . . . .. .

Encl – Part B,C and D of the application

along with enclosure 1 to ……….

(Signature)

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

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Advertisement No. Application form6459 Part B No ………….

dated 18/03/2016 (for office use only)(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) (Surname)

4. Father's name : ………………………………………………………………(Name) (Surname)

5. Present address : ………………………………………………………………

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

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Advertisement No. Application form6459 Part C No ………….

dated 18/03/2016 (for office use only)(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) (Surname)

4. Father's name : ………………………………………………………………(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: . . . . . . .. . . . . . . . . . . . . . . . .

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Advertisement No. Application form6459 Part D No ………….

dated 18/03/2016 (for office use only)(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) (Surname)

4. Father's name : ………………………………………………………………(Name) (Surname)

5. Service and experience details :

Name & DesignationBrier

Period of Placeemployment ofS. full Salary

description postingNo. address of At first As on (In Rs.)of work From To (office/

employer posting today field)

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 …. to ….. Details of work Approx cost of executed workexecuted in Rs .Lakhs

(Signature of applicant)

Name of the Applicant: . . . . . . .. . . . . . . . . . . . . . . . .

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