ASSAM (GAZETTE PART-IX)

STANDARD FORM OF APPLICATION

To........
.........................
Name
of
Post.........................
.........
Department/Office..........
.......................
1)
Name
in
full(Block
letter)
:.
..................................................
2)
Present
Address
Vill/Town..
..........................
P.O..
P.S........................
3)
Fathers
Name
&
Address
..........................
............................
..........................
4)Place
of
birth
including
Police
Station
&P.O.
............................
5)Are
you
a
citizen
of
India
&
if
so
how?
............................
(Copy of citizenship certificate should be
enclosed where necessary)
6)Educational qualification & also the name
& full add of the institute in which read last
(copies
of
certificate
should
be
enclosed)
.............................
Exam passed Name
of
theYear of Exam Roll No
Division/
Name of the
board/Council/
Class
Institution
University

7).Other
qualification:
.....................................
(a)
8)
Community:
.............................
(b) Are you a member of Scheduled Cast/Schedule
Tribe(Answer
yes
or
no)
if
yes
give
.............................
Particulars supported by a certificate copy
Of which should be enclosed.
9) (a) Age on the 1st January199 /2000(According
to HSLC certificate copy of which should be enclosed
(c)
Exact
age
on
date
of
the
application.............................
10)
Present
occupation
if
any.................................

11)
Previous
appointment
held,if
any.
...............................
12) Are you a temporary or retrenched personal
of temporary Department of the Govt. of Assam
(Answer
yes
or
no,state
particulars)
............................
13) Are you trained in or a member of the N.C.C. or
Territorial army or trained Home guards and Civil
Defence
volunteers,if
so
give
particulars.............................
14)
Employment
Registration
No.
.................................
15) Wheter there is any Govt./ Semi Govt
Employees in your familyif any,particulars
of such family like relationship,name of the job,
pay drawn,place of posting,permanent/temporary
etc
should
be
furnished.
..................................
16) Familys income certificate from the Gaon
Panchayat/DC/SDO/Circle
Officer
to
be
furnished..............................
17)Examination
Centre..................................
I
am
a
candidate
for
the
post
of..............................
And the stated above are true to the best of my knowledge and behalf. In case of any false statement , I am
liable to any action the Government deem fit and proper.
A treasury challan of Rs..is attached herewith.
Date:
Place:

SIGNATURE OF THE APPLICANT