o APrLrcATroN FoRM.

To
The District Welfare Officer, Affix passport

Size

CATEGORY OF POST APPLIED FOR

(Notification No I Dt-.-_)

1. Full name of the candidate.

(in Block Capital Letters)

2. Father's / Husband's name.

Permanent Address.

4. Present Address.
(for correspondence)

q Whether SC / ST i SEBC / OBC I PH I

Ex - Serviceman.
(xerox copy of the cerlificates to
be attached in support of the claim)
o. Gender (Male / Female) :.

7. Date of Bir'th as recorded in :

the Matriculation certificate.

8. Age as on 30.11.2021 Years

[-l'n
9. Name of the Employment Exchange
andRegistration No.

10 Educational Qualification :

__(&ttg g!_g*e lf -attested xe ro x co p y 9f ce rt if ca t_qs

- i

I rrarne
Name of the ' Year
oitne I|
Vea, of
or Iioard/
Board/ Percentage
Ill ixamination Passing
iPassing] Unlversitv
UniversitV (wrthout secured. of marks
]
lll
=xaminatron I

1
rl 2_
I

:--l
extra
,o-plLqrl)
(without extra secured

I I- _ _q 4
t-- --" r
-i**-l-
i

ll
N.B.: Marks secured in Extra optional / Ancillary / Foundation subject should not be
included for calculation.

11. List of enclosures

DECLARATION
I do hereby declare that all the statements made in this application are true, complete and
correct to the best of my knowledge and belief. I have read the details in the advertisement notice
and do hereby declare that I fulfil all the conditions of eligibility prescribed" ln case of any of the
statement / particulars is /are found to be given wrong during or after the selectton, my candidature
for the said post will be cancelled / forferted by the authority.

Place Signature of the candidate.

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