5/17/23, 5:38 PM Digital Application for Matric Level Group C Posts under Andaman and Nicobar Administration

Closing date:19.05.2023
  Print Annexure

RECRUITMENT FOR MATRIC LEVEL POSTS UNDER A & N ADMINISTRATION

APPLICATION FORM

Signature of Candidate Thumb impression

Your Application Number : 21741 Printed on 17-05-2023

Choice of Posts made by candidate.
Choice 6:
Choice 1: Assistant Choice 4: Bill
Choice 3: Bearer Choice 5: Boat Keeper - Chainman -
Store Keeper - Choice 2: Ayah - DHS Distributor -
(Tourism) - IP&T NCC (Naval) Directorate of
Transport Electricity
Agriculture
Choice 8: Field
Choice 7: Bus Choice 9: Hostel Choice 10: Lab Choice 12: Lascar
Assistant - Office of Choice 11: Lab
conductor - Attendant - Attendant - - Forest &
Commissioner Food Attendant - MGGC
Transport Education AH&VS Environment
Safety
Choice 17: MTS
Choice 15:
Choice 13: Lascar Choice 14: Log Writer Choice 16: MTS - (Including safaiwala) - Choice 18: MTS
Mazdoor -
- NCC (Army) - Transport AH&VS Civil Supplies & (Tourism) - IP&T
Transport
Consumer Affairs
Choice 20: MTS - Choice 22: MTS -
Choice 21: MTS - Choice 23: MTS (Peon, Choice 24: MTS
Choice 19: MTS - Directorate of Directorate of
A. Directorate of Chowkidar Sweeper/ (IP Division) -
DC (SA) Economics & Sports & Youth
Fisheries Safaiwala) - DIC IP&T
Statistics Affairs
Choice 28: MTS - Choice 30: MTS -
Choice 25: MTS - Choice 26: MTS - Choice 27: MTS -
Forest & Choice 29: MTS - JNRM Labour
APWD CPAO Electricity
Environment Department
Choice 31: MTS - Choice 32: MTS - OL, Choice 33: MTS - Choice 34: MTS - Choice 35: MTS - Choice 36: MTS -
MGGC Department PMB Raj Niwas RD,PRIs&ULB RCS
Choice 39: Multi-
Choice 42: Safai
Choice 37: MTS - Choice 38: MTS - Tasking Staff - Choice 40: Munshi Choice 41: Painter -
Karmachari -
Secretariat TGCE Directorate of - Transport Transport
District Jail
Agriculture
Choice 43: Safai
Karmachari - Choice 44: Choice 45: Choice 46: Tea Choice 47: Ward
Forest & Safaikarmchari - DSS Safaiwala - DHS Maker - DSS Attendant - DHS
Environment

B. Exam Centre Opted Port Blair

1 Name of Candidate ( as recorded in SSE (X) pass certificate) only SAJAL NAHA
2 Father's Name PABITRA NAHA
3 Mother's Name BAKUL NAHA
4 Gender Male
5 Marital Status Unmarried
(a) Date of Birth ( as recorded in SSE (Xth) pass certificate by
6 09-05-2004
CBSE/Board)
(b) Age as on 19.05.2023 19 Years and 0 Months
7 Nationality INDIAN
NIMBUDERA,MAYABUNDER,NORTH AND MIDDLE
8 Permanent Address ANDAMAN,ANDAMAN AND NICOBAR
ISLANDS,744201

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5/17/23, 5:38 PM Digital Application for Matric Level Group C Posts under Andaman and Nicobar Administration

NIMBUDERA,MAYABUNDER,NORTH AND MIDDLE

Address for communication (Village, Post Office, District and State
9 ANDAMAN,ANDAMAN AND NICOBAR
with Pin Code )
ISLANDS,744201
10 Mobile Number 8900956038
11 EmailID sajaldrsi18@gmail.com
12 (a) Category Unreserved
No.
13 Are you physically challenged?
Percentage of Disability:
14 Are you suffering from Cerebral Palsy? No
15 Are you a Meritorious Sportsperson as per Vacany Notice? No
Are you an Ex servicemen eligible for reservation under this
16 No
category?
17 Are you a resident of Andaman and Nicobar Islands? Yes
18 Employment Registration Card Number 100562/2022/MB/0013
19 ID Proof and Number PAN Card, ID Proof Number :CYSPN8301D
Do you possess essential/ minimum educational qualification for
20 Yes
the applied posts?

21 Educational Qualifications (X Std)

S.No Name of Exam University/Board Certificate Serial No. Year of passing
1 SECONDARY SCHOOL EXAM CBSE 0593545 2020

Are you ever employed on regular basis in any department/undertaking. If yes give details with
22 No
proof. Name of the post being held.
Are you seeking relaxation of age in terms of Admin's Circular dated 06.06.2001 & dated
23 No
09.09.2011? If so attach separate application alongwith all documentary evidences

I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge,
information and belief. I understand that in the event of any information being found false or incorrect or ineligibility being
detected at any stage i.e before or after the examination/appointment , my candidature/ appointment is liable to be cancelled. I am
aware that if I contravene this declaration, my candidature will be rejected summarily by the Administration.

I have read the provisions in the Notice of the Administration carefully and I hereby strictly undertake to abide by them.

I further declare that I fulfill all the conditions of eligibility regarding age limits, educational and other qualification etc. prescribed
for appointment to the post.

Place :
Date : 17-05-2023

Signature of the applicant

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