Assam Gazatte Part-IX Standard Form

Assam (GAZETTE PART-IX)

STANDARD FORM OF APPLICATION To, The……………………………………………………………............. Name of post…………………………………………......................... Department/office…………………………………………………….

1. 2.

Name in full (Block Letter) Present Address

3.

Phone Number

4.

Father’s Name/Husband’s Name

5. 6. 7.

Passport Size Photo

:………………………………….............................. : Vill:……………………..P.O. :…………………… Dist :…………………......PIN :…………………… :……………………………………………………… :……………………………………………………… Vill :……………………..P.O. :…………………… Dist :……………………..PIN :……………………

Place of birth including Police Station :Vill……………………….P.O…………………….. Are you a citizen of India if so how?(Copy of citizenship Certificate should be enclosed) :……………………………………………………… Educational Qualification and also the name and full address of the institution (Copies :……………………………………………………… of certificate should be enclosed) :………………………………………………………

8. 9.

Other qualification Community (A) State your religion (B) Are you member of Schedule Caste/

:……………………………………………………… :……………………………………………………… :………………………………………………………

10.

(A) Age on the 1st January 20.....(According

Schedule Tribe (Answer ‘Yes’ or ‘No’) :……………………………………………………… to the H.S.L.C. certificate copy)

11. 12. 13. 14. 15. 16.

(B) Exact age on date of application Present Occupation if any Previous appointment held, if any

:……………………………………………………… :……………………………………………………… :……………………………………………………… :……………………………………………………….

Are you a temporary of retrenched personal Of temporary Department of the Govt. of Assam (Answer ‘Yes’ or ‘No’) :………………………………………………………. Are you trained in or a member of the National Cadet Crops or Territorial Army or trained Home Guards :………………………………………………………..

Employment Registration No.

:………………………………………………………..

17.

Whether is any Gov./Semi Govt. Employees :……………………………………………………….. in your family member Family income certificate from de Gaon Panchayat/ DC/SDO/Circle Officer to be Furnished :………………………………………………………..

18.

Examination Centre

:…………………………………………………

I am a candidate for the post……………………………....and the stated above are true to the best of any knowledge and behalf. In case of any false statement, I am liable to any action the Government deem fit and proper. A treasury challan Rs………………………………..is attached herewith.

Date :___________________ Place :___________________ SIGNATURE OF THE APPLICANT