CABINET SECRETARIAT

Note: please fill the application form in English Capital letters.

Advt.No. 06/13 Post applied for (Tick ‘ √ ’ against relevant post)

Lower Division Clerk

Assistant

1. Name :

2. Address for Correspondence : (Please mention PIN codeand name of STATE clearly)

3. Contact No.(Mobile/Landline) :

4. Father’s Name :

5. Date & Place of Birth :

6. Age as on closing date : (as on 14.02.2014)

7. Code for category :(Refer note II)

8. If ex-serviceman, please indicate:-

i) Length of Service :

ii) Date of Joining : ___________________

iii) Date of Discharge (Enclose copy of discharge : ____________________

Certificate)

9. Sex : ____________________

10. Nationality : ____________________ 11. Religion : ___________________

12. Marital Status : ___________________

If married, a) Religion of Spouse :______________ b) Nationality of Spouse : ___________________

Contd…

13. Educational Qualifications:-

PIN

STATE

Years Months Days

Years Months Days

Exam/ Degree Passed

University/Board Year ofPassing

Duration of theDegree/Diploma

Subjects Studied Aggregate markswith Percentage

14. Whether employed or not : ___________________________________

15. If Yes, Details of Employment in Chronological order:-

Office/Institute/organisation

Post Held Ad-hoc/Regular/Tem./Pmt.

Exact date to begiven

Scale of Pay Nature ofDuties

From To

16. Computer Knowledge, if any : _____________________________________

17. Typewriting speed : _____________________________________

18. Language Known (Indian/Foreign) : With proficiency to read, write & speak

19. Examination Centre : ( Tick’ against relevant column)

(Note: The Department reserves the right of final allotment of examination center)

D E C L A R A T I O N

I hereby declare that a) I fulfill the eligibility for the post applied for ; b) I have not submitted anyOther application in response to the same advertisement. In the event of information or part thereof being found incorrectAt any stage, my candidature/appointment is liable to be cancelled / terminated without any notice to me and action can be taken against me.

Place :Date: Signature of the applicant

Language Read Write Speak

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