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.

Fathers Name/Husbands 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