RECRUITMENT FOR WATCHMAN

Advertisement No. Rec./Hyd/Cat.IV/01/2017

REGISTERED APPLICATION FORM
Application Form for the Post of : Watchman
Registration Number : 2172041843
24. Photo
1. Candidate's Name : SIPUN KUMAR NAYAK
(Name as recorded in the School /
Matriculation / Birth Certificate etc.)
2. (a) Father's Name : PRASAN KUMAR NAYAK
(b) Mother's Name : LAXMIPRIYA NAYAK
3. Gender : MALE
4. Date of Birth : 02-May-1993
(As recorded in the School /
Matriculation / Birth Certificate etc.) 25. Signature
5. Age (as on 01.07.2017) : 24 Year(s) 01 Month(s) 29 Day(s)
6. Category : OBC
7. Whether Domiciled in the State of : NO
Jammu and Kashmir during the period
01-01-1980 to 31-12-1989
8. Whether Ex-Servicemen : NO
9. Whether Person with Disabilities (PWD) : YES
/ Physically Handicapped (PH)
Nature of Disability : OH-OL
Degree of Disability (in %) : 40
10. Whether Departmental (FCI) Employee : NO
11. Minority Community : Not Applicable
12. Nationality : INDIAN
13. States/UTs for Posting (in order of : Andhra Pradesh, Telangana, Andaman and
Preference) Nicobar Group of Islands
14. Exam City (in order of Preference) : Srikakulam, Vishakhapatnam, Guntur
15. Language of Written Test : English
16. Post Applied For : Watchman
17. Educational Qualification
(a) Name of Qualification (which makes : 8th Standard Pass
you eligible)
(b) Date of Issue / Acquiring Qualification : 06-Jul-2009
(c) Name of the School / Authority / : B.S.E ODISHA
Board
(d) Whether Govt. Recognized : YES
18. Higher Qualification
(a) Have you completed Matriculation (10th : YES
Std.) ?

Sl.No. Name of Examination School/College Name Year of Passing % of Marks

Passed
1. Matriculation ug govt high school 2009 43.17
Note: In case of CGPA / OGPA or Grade, mention equivalent percentage of marks as per University /
Institute norms. Percentage of marks not to be rounded off.
(b) Details of Higher Qualification (if applicable)

Sl.N Name of Stream of the School/College Name Year of Passing % of Marks

o. Examination Examination
Passed
1. Intermediate/10+2 DIPLOMA IN ORISSA SCHOOL OF 2014 58
MECHANICAL ENGINEERING
Note: In case of CGPA / OGPA or Grade, mention equivalent percentage of marks as per University /
Institute norms. Percentage of marks not to be rounded off.
19. Email Id : SIPUN.NAYAK93@GMAIL.COM
20. Mobile Number : 9861542021
21. Address Details
Address Line 1 : ATPO SASANAPADARA VIA GOLANTHARA
Address Line 2 : BIG STREET
District : GANJAM
City : BERHAMPUR
Pin Code : 761008
State : Odisha
22. Whether FEE Paid : Exemption Claimed

23. Declaration
1. I have not submitted any other application for this examination. I am aware that if I contravene this rule, my
application will be rejected summarily by FCI.
2. I have read the provisions in the Advertisement carefully and hereby undertake to abide by them.
3. I further declare that I fulfill all the conditions of eligibility regarding age limits, educational qualifications etc.
prescribed for the post applied for.
4. I also declare that I do not stand debarred by FCI as on date and have never been convicted by any court of law.
I also declare that no charge sheet is pending against me in any court of law. Further declare that I have never
been dismissed or compulsorily retired from the service of the Corporation or from a Department of a State or the
Central Government or from any Public Sector Undertaking or my service been terminated during probation.
5. For Candidate belonging to OBC -
I declare that I belong to the community, which is recognized as backward class by the Govt. of India for the
purpose of reservation in services as per order contained in Deptt. of Personnel and Training Office
Memorandum No. 36012/ 22/ 93-Estt.(SCT) dated 8.9.1993. I also declare that I do not belong to the person /
sections (creamy layer) mentioned in column 3 of the schedule of the OM mentioned above and modified vide
Govt. of India DOPT OMs mentioned in the Advertisement. I further declare that I am in possession of OBC
Certificate in the prescribed format given in the Advertisement.
6. I hereby declare that there is no Vigilance / Disciplinary case pending against me. I am in possession of No
Objection Certificate from my employer which shall be required to be sent along with other essential enclosures
in case of my shortlisting on the basis of the Written Test at the designated Address which shall be informed /
notified through the designated website (www.fciregionaljobs.com)
7. I hereby declare that self-certified copies of relevant certificates / documents are in my possession. In case, self-
certified copies of the relevant certificates / documents are not provided by me along with the Registered Online
Application Form Printout, if called for, my candidature will be cancelled without any notice.
I hereby declare that all the information given/ statements made by me in the application are true, complete and
correct to the best of my knowledge and belief and nothing has been concealed or suppressed. In the event of any
information being found false or incorrect or is not in conformity with the eligibility criteria mentioned in the
advertisement at any point of time my candidature / appointment may be cancelled / terminated without any notice
and / or I shall be liable for any other action under the extant rules.

Date: 11-Aug-2017 Signature of Candidate: _______________

Place: ____________ Candidate's Name (in Capital Letters): _______________