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KERALA PUBLIC SERVICE COMMISSION

APPLICATION FORM

Category No 477/2010 Barcode : E1100889

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Name of post : LOWER DIVISION CLERK (DIRECT RECRUITMENT)( ERNAKULAM ) Scale of Pay: Rs. 5250-8390/Department / Company/ Corporation/Board/local Authority/Co-operative Institution : VARIOUS DEPARTMENTS/KWA/KK&VI BOARD/MUNICIPAL COMMON SERVICE ETC; Gazette Date : 31/12/2010

1. Name with Initials (IN BLOCK LETTERS)

ANEESHA DEVASSY

KALATHIPARAMBIL HOUSE, ROSE VILLA, NEAR SWTSA,,ALUVA 2.(a) Address to which communications are to be ERNAKULAM,683101 sent (IN BLOCK LETTERS) aneesharose@gmail.com Mobile: 9446214795 (b) Permanent Address 3.(a) Date of Birth ( In figures and Words) (b) Sex 4. Are you eligible for communal reservation? (Yes/No) 5.(a) Religion (b) Community/Caste/tribe with sub-caste 6.(a) Educational Qualifications (b) Experience, if any NIL 7. (a) Name of Mother/Father/Guardian (Specify relationship) (b) Mother Tongue K. J. DEVASSY,FATHER MALAYALAM KALATHIPARAMBIL HOUSE, ROSE VILLA, NEAR SWTSA,,ALUVA ERNAKULAM,683101 8/9/1982, EIGHTH SEPTEMBER NINETEEN EIGHTY TWO FEMALE YES CHRISTIAN LATIN CATHOLICS/ ANGLO INDIAN,LATIN CATHOLICS PASSED THE SSLC EXAMINATION CONDUCTED BY THE BOARD OF PUBLIC EXAMINATION OF KERALA, IN THE YEAR 1998, WITH DISTINCTION.,(1,)

8. (a) Nationality (b) State, District and Taluk to which you belong 9. (a) District/Circle to which you apply (In the case of District wise selections) (b) Have you applied for the post in any other district as per this notification? (Yes/No) 10. Are you eligible for relaxation of upper age limit? if so give details

INDIAN KERALA,ERNAKULAM,ALUVA ERNAKULAM No

NO

11. Are you entitled to weightage / Priority being Sportsman/Ex-serviceman/Physically NO WEIGHTAGE Handicapped? NO PRIORITY Give details 12. Are you employed on a regular basis under State or Central Government? Give details NO

13. Are you presently ineligible to apply for the post on account of debarment by Public Service Commission, dismissal from service or conviction NO by a Court of Law? Give details DECLARATION I hereby declare that all the particulars furnished above are correct and complete to the best of my knowledge and belief and that I am in possession of the documents in proof of the claims made in this application. Place : ALUVA Date : 08/02/2011 1:59:37 PM sd Signature