O F F L I N E A P P L I C A T I O N

Application to be Addressed

General Manager (A/MP&R) Mahanadi Coalfields Ltd. PO Jagruti Vihar, Burla Dist. Sambalpur Odisha 768020

PASTE YOUR PASSPORT SIZE RECENT COLOUR PHOTOGRAPH

(Fill up the following details in BLOCK letters)

Advertisement Ref No. Post Applied For Name Father / Husband's Name Mothers Name Caste (SC/ST/OBC/Gen) Whether Ex Serviceman? Defence Identity Card No. Defence Service From Defence Service To YES / NO

F O R M A T F O R

Whether Physically Handicapped? Type of Disability (Tick which ever is applicable) Date of Birth Sex (Tick which ever is applicable)

YES / NO Orthopaedically Handicap D D M M Y Y Female Y

Percentage of Disability Hearing Handicap Y Age on cut-off date Height In cm Visually Handicap
Year Month Day

Male

(Tick which ever is applicable)

Mining Sirdarship Certificate issued by DGMS Overman Competency Certificate VALID TILL VALID TILL VALID TILL VALID TILL VALID TILL Address for Communication C/o House/Flat/Qrts. No Road/St/Mohala/Pada D D D D D D D D D D M M M M M M M M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

S T A T U T A R Y P O S T S

Survey Certificate of Competency First Aid Certificate Gas Testing Certificate

Area/Locality/Village Post Office Town/City State Telephone E-mail District Pincode Mobile

Permanent Address C/o

O F F L I N E A P P L I C A T I O N

House/Flat/Qrts. No Road/St/Mohala/Pada Area/Locality/Village Post Office Town/City State Telephone E-mail Employment Exchange Registration Details. Registration Number Name of the Exchange Yr of Registration District Pincode Mobile

Qualification Details Duration of Course Divisi on/ Grade

Sl No

Examination Passed

Stream

Year of Passing

Name of the Institute

Board/ University

%age

F O R M A T F O R
Sl No Organization Name

Experience Details Post Held From Date To Date Description

S T A T U T A R Y P O S T S

Declaration I do here by declare that the above information as furnished by me is true to the best of my knowledge. I further give undertaking that at any point of time, if any of the above Information found false, it will automatically lead to cancellation of my candidature and will also be liable for prosecution under law.

Date:

Signature of Candidate