DIPLOMA PANEL FORM

Application form for empanel the name in the Diploma Engineers Panel list
mentioned in the Office of the Chairmen, Committee of Chief Engineers and
Concerned Heads of Departments and Engineer-in-Chief (Civil), Orissa Nirman
Soudha, Bhubaneswar.

1 Name (in Capital Letters)

2 Father’s Name
3 Address (in Capital Letters) (I) Permanent:-

(II) Present:-

4 Name of Engineering School

5 Year of Passing Diploma
6 Name of Discipline/Trade
7 Total Mark secured in Diploma
Engineers
8 Date of Birth
9 Sex
10 Whether SC/ST/SEBC/General
11 In case if Sportsman/Ex-
Serviceman/Physically Handicapped,
give details
DOCUMENTS TO BE PRODUCE
1 Xerox copy of High School Certificate
(Matriculation) Duly attested
2 Xerox copy of Diploma certificates
duly attested
3 Xerox copy of Diploma Mark sheet
duly attested.
4 Xerox copy of certificate in support of
physically handicapped/Sports Man/
Ex Service Man
 Sri/Smt/Miss………………………………..Son/Daughter of …………………..

I, do here by under take that the information given are true/correct. In case of any
information given proved false, I will be abided to obey the decision to be taken by
the Committee in the matter.

Date:

Place: Signature of the Candidate