ASSAM (GAZETTE PART-IX)

     STANDARD FORM OF APPLICATION

To………………………………………………………………………………………………………….................................

Name of Post……………………………………………………………………………………………..................................

Department/Office……………………………………………………………………………………….................................

1) Name in full(Block letter)      :………………………………………………….…………..................................................

2) Present Address                                              Vill/Town….……………………………….……………..........................

P.O…..…………P.S………………………………………........................

3) Father’s Name & Address                             ……………………………………………………………..........................

                                                                              ……………………………………………………………............................

                                                                                ……………………………………………………………..........................

4)Place of birth including Police Station &P.O……………………………………….…………………............................

5)Are you a citizen of India & if so how?      ……………………………………………………………............................

(Copy of citizenship certificate should be

enclosed where necessary)

6)Educational qualification & also the name

& full add of the institute in which read last

(copies of certificate should be enclosed)     …………………………………………………………….............................

 7).Other qualification: ………………………………………………………………………………….....................................

(a)     8) Community:                                             …………………………………………………………….............................

(b)     Are you a member of Scheduled Cast/Schedule

Tribe(Answer yes or no) if yes give        …………………………………………………………….............................

Particulars supported by a certificate copy

Of which should be enclosed.

9) (a) Age on the 1st January199 /2000(According

to HSLC certificate copy of which should be enclosed

(c)     Exact age on date of the application………………………………………………………………….............................

10) Present occupation if any…………………………………………………………………………….................................

11) Previous appointment held,if any………………………………………………………….…………...............................

12) Are you a temporary or retrenched personal

of temporary Department of the Govt. of Assam

(Answer ‘yes or  no’,state particulars) ……………………………………………………………………............................

13) Are you trained in or a member of the N.C.C. or

Territorial army or trained Home guards and Civil

Defence volunteers,if so give particulars………………………………………………………………….............................

14) Employment Registration No. ……………………………………………………………………….................................

15) Wheter there is any Govt./ Semi Govt

Employees in your familyif any,particulars

of such family  like relationship,name of the job,

pay drawn,place of posting,permanent/temporary

etc should be furnished.                             ………………………………………………………………..................................

16) Family’s income certificate from the Gaon

Panchayat/DC/SDO/Circle Officer to be furnished………………………………………………………..............................

17)Examination Centre……………………………………………………………………………………..................................

                I am a candidate for the post of…………………………………………………………………..............................

And the stated above are true to the best of my knowledge and behalf. In case of any false statement , I am liable to any action the Government deem fit and proper.

                A treasury challan of Rs………………..is attached herewith.

Date:

Place:                                                                                           SIGNATURE OF THE APPLICANT