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 Candidates
APPLICATION FOR THE POST OF Photo

(DISTR|CT CO-ORDINATOR / ASSISTANT DISTRICT CO-ORDINATOR /

TOWN CO-ORDINATOR)

1 Name of the Applicant

rt
tL Father / Husband Name

3 Date of Birth & Age

as on 01.08.2020

4. Gender (Male / Female)

5. Address for communication

6 Permanent Address

7 Community

8. Mobile Number

L e-Mail

10. Aadhaar Number

11. Nativity
(Attested certificate must be
enclosed)
Nationality

12. Educational Qualification 1otn lnter Degree P.G. Others

(Attested certificates must be
enclosed)
Year of Passing (MMIYY)
% of Marks Secured
{3. Technical Qual ification

14. Experience as per Notification

Roc. trl o. 2115I 2020 - A1,
dt,19,08,2A20

Ppc_lar?!io,n: I hereby declare that all the entries made by me are true, complete and correct to the best of
my knowledge and belief. ln the event of any information being found false or incorrect or ineligibility being
detected before or after the selection, the Higher Authorities can take action against me as per the rules. ln
case it detected that I have misled the Higher Authorities on any issue, I will be solely responsible for all
penal consequences thereof.

Place :

Date Signature of the Applicant.