STATE LEVEL POLICE RECRUITMENT BOARD, ANDHRA PRADESH - 2016

FILLED IN ONLINE APPLICATION FORM

Recruitment for the posts of SCT SI (Civil) (Men & Women)- Post Code No.11,SCT RSI (AR) (Men & Women)-Post Code
No.12, SCT RSI (SAR CPL) (Men) - Post Code No. 13, SCT RSI (APSP) (Men)- Post Code No. 14, Deputy Jailor (Male)-
Post Code No. 51 and Assistant Matron (Female)-Post Code No. 52, in Prisons and Correctional Services Dept.,-2016,
vide Notification No. 208/R&T/Rect.I/2016, dt:- 17.09.2016.

1. Candidate's Name : GUDALA PAVAN KUMAR

2. Father's Name : GUDALA NAGESWARA RAO
Preserve the REGISTRATION NUMBER
3. Mother's Name : MEENAKSHI for all your future correspondence.
4. Gender : Male REGISTRATION NUMBER
5. Date Of Birth : 06-Jul-1991
6. Community : BC-B
5053500
7. SSC Or Equivalent Roll No.(Hall Ticket No.) : 0303268 Pass Year : 2006
Educational Qualification : B.SC. 11.
8.
9. Highest Qualification : --
10. Upload Community Certificate(BC/SC/ST) : Uploaded
(i) If BC-E candidate, caste name : --
13. Identification Marks (as per 1. : A MOLE ON THE LEFT ELBOW
SSC or Equivalent)
2. : A MOLE ON THE THROAT
14. Candidate Mobile No. : 9000809984
15. E-mail ID : pavankumar91619@gmail.com
12.
16. Address for Communication : DOOR NO 4-70
VENKATAYAPALEM
ACHANTA VEMAVARAM ACHANTA MANDAL
WESTGODAVARI DISTRICT
PIN: 534267
17. Do you have an Aadhar Card : Yes
Aadhar Card No. : 805535708737
18. What is your preferred medium of Exam : Telugu
19. Which is your preferred place for : Vijayawada
writing Preliminary Written Exam

20. Select Post Preference 1st : 11 - SCT SI (Civil) (Men & Women)
2nd : 12 - SCT RSI (AR) (Men & Women)
3rd : 51 - Deputy Jailor (Male)
4th : 13 - SCT RSI (SAR CPL) (Men)
5th : 14 - SCT RSI (APSP) (Men)
21. Are you presently a local of State of Andhra Pradesh : Yes
If Yes, What is your Local District : West Godavari
If No, Which State you belong to : --
If you have selected 'Telangana' as State to which you belong, as per GSR 591E of Govt. of : --
India, Candidates who migrate from Telangana to Andhra Pradesh with in a period of 3 years
from the 2nd Day of June, 2014 shall be regarded as local candidate in Andhra Prades. Do
you belong to this Category ?

22. Are you an Employee of Govt. of Andhra Pradesh. : No

23. Do you claim benefit of Age relaxation / Reservation / Physical Events / Under : No
Ex-Servicemen Quota
24. If you are BC Candidate, you are eligible for reservation quota, if you do not : I do not belong to Creamy Layer
belong to Creamy Layer

25. Do you claim benefit of Physical Measurement under ABO-ST : No

(i) If Yes, What is your Native District : --
(ii) What is your Native Scheduled Area : --
26. Do you claim benefit of Special Reservation under any one or more of the
: PE : No PM : No MSP : No
following categories (for Post Code Nos. 11,12,13,14)
CPP : No CDI : No NCC : Yes
27. Do you claim benefit of special reservation under CJP for Post Code No. 51 (Male) : No
28. Do you claim benefit of Age-relaxation under Army, Naval or Air Force of the Union. : No
29. Do you claim benefit of Age-relaxation under NCC (Worked as Instructor) : No
30. Do you claim benefit of Age-relaxation under temporary employee in the State Census : No
with a minimum service of 6 months during 1991.

31. Fee Paid through : AP Online Transaction Id./Reference Id. : APPRC3F76F14B9 Amount (in Rs.) : 600

I Certify that I have read the Notification and I am proceeding to submit this application form after having understood
the eligibility and other criteria mentioned in the Notification. I undertake total responsibility for submitting correct
information to the best of my ability.

Date: 15-Oct-2016 14:45 PM