APP LICATION FORM

APPLICATION FOR THE POST OF …………………………………

Space for
photograph
01. Name (in capital letters)

02. Date of Birth

(as recorded in Matriculation Certificate)

03. Age (as on 01.11.2010)

04. Sex

05. Nationality

06. Marital Status

07. Father’s/ Husband’s Name

08. Languages known

09. Permanent Address with

Telephone / Mobile No. & e-mail ID(if any):

10. Address for communication with

Telephone / Mobile No. & e-mail ID(if any):
 -2-
11. Educational Qualification (Starting from Matriculation onwards)
Exam. Name of Board/ Council Discipline /Subject Year & % of
Passed Institution month of marks
passing

12. Whether Passed Oriya as one of the language papers in Matriculation Exam. (Please Tick): YES / NO
(If Yes, please enclose attested copy of the Certificate)

13. If Sl. No. 12 is No, whether Passed Oriya Language Test of ME Standard (Please Tick): YES / NO
(If Yes, please enclose attested copy of the Certificate)

14. Work Experience*

Name of the Designation & Period of Service Details of experience
organisation Scale of Pay From To

* Please furnish Experience Certificate

15. Any other information candidate would like to furnish (training attended, certification etc.):
{Please attach separate sheet(s)}

DECLARATION
I, do hereby declare that the information furnished above are true to the best of my knowledge
and belief. In the event of any information / certificate / document / credential being found
false or incorrect, my candidature / appointment may be cancelled / terminated without any
notice.

Place:
Date : Signature of the Candidate.