PROFORMA OF APPLICATION POST APPLIED FOR :

1. Name & Address of the applicant with E-mail Address & Cell No.:

Affix a recent Passport size Photograph

2. Date of Birth:-

3. Date of entry into service:-

4. Date of retirement under Central / State Govt. Rules:5. Educational Qualifications:-

a. Whether educational & other qualifications required for the post as per the notification are satisfied (if any qualification has been treated as equivalent to the one prescribed in the rules, state the authority for the same)

Essential: Sl. No. 1.

State Qualifications / Experience required as per notification

2. 3. 4. 5.

Page 1 of 4

State Qualifications / Experience possessed by the officer

6. Please state clearly whether in the light of the entries made by you above, you meet the requirements of the post or not:

Sl. No.

1. 2. 3. 4. 5.

7. Details of employment in chronological order. Enclose a separate sheet, duly authenticated with your signature, if the space below is insufficient:

Office/Institution/ Organization

Post held

From

To

Nature of appointment whether regular/adhoc/ deputation

Scale of pay and Basic Pay therein

Nature of Duties performed

8. Nature of present employment i.e., ad-hoc or temporary or quasi-permanent or permanent: 9. In case present employment is held on deputation / contract basis, please state: a) The date of initial appointment: b) Period of appointment on deputation / contract: c) Name of the parent Office / Organization to which you belong:

10. Please state whether working under: a) b) c) d) e) f)

Central Government State Government Universities Autonomous or Statutory Organizations Recognized Research Institutions Private Organizations

11. Are you in a revised scale of pay? If yes, give the date from which the revision took place and also indicate the pre-revised scale: 12. Total emoluments drawn per month with break up or Basic Pay, GP, DA etc. 13. Additional information, if any, which you would like to mention in support of your suitability for the post. Enclose a separate sheet, duly authenticated with your signature, if the space below is insufficient: Page 2 of 4

14. Whether belongs to SC/ST/OBC:-

(Note: OBC candidates should produce “Form of Certificate for applying for posts under GoI”, the proforma for submission is attached with application format)

15. Copies of Annual Confidential Reports (ACRs) for the last 5 years:16. Name & Addresses of two references:-

17. Any other information not covered in the above columns. 18. List of enclosures: DD Particulars

Certificate

Certified that the information furnished above is true and correct to the best of

my knowledge and belief. If any information is found to be willfully suppressed or found

not correct, I will forego my employment and abide by any disciplinary action by the Competent Authority. Date:

Signature of the Candidate

Address…………………

Certificate (to be issued by the forwarding Authority)

It is certified that the particulars furnished above are correct and no disciplinary

case is either pending or contemplated against the officer and no penalty, major or

minor, was imposed on the officer during the last 10 years and his integrity is beyond doubt.

Signature of the Head of Department with (Stamp) Page 3 of 4

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA This is to certify that Shri / Smt. / Kumari ______ son / daughter of

________ of village / town __________ in District / Division __________ in the State / Union Territory

______________ belongs to the ________________

community which is recognized as a backward class under the Government of India,

Ministry

of

Social

Justice

and

Empowerment’s

Resolution

No.________________ dated ________*. Shri / Smt / Kumari ________ and/or his/her family ordinarily reside(s) in the _______ District / Division of the

________ State / Union Territory. This is also to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the Government of India, Department of Personnel and Training O.M. No. 36012/22/93-Estt. (SCT), dated 8-9-1993**.

District Magistrate Deputy Commissioner, etc.

Dated: Seal

* The authority issuing the certificate may have to mention the details of Resolution of Government of India, in which the caste of the candidate is mentioned as OBC. ** As amended from time to time.

NOTE – The term “Ordinarily” used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.

Page 4 of 4

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