APPLICATION FORM
To
The Deputy General Manager
Regional Office
Vijaya an!
No"#$%#%&'Ma(ji) *treet
*treet'Maruthinagar
Vijaya+a)a'Ap
PIN , -.///&
With reference to your advertisement in ___ONLINE____ dated _03-07-201_! I su"mit
my a##$ication in the #rescri"ed format%
Name of the #ost a##$ied for & 'EON
1% ()TE*O+, TO W-I(- I .ELON*& /(& /T& O.(& *EN&
0Indicate "y mar1 in a##ro#riate "o2%3
2% 45LL N)6E IN .LO(7 LETTE+/& 0Leave one s#ace "$an1 "et8een t8o #arts
of your name3
6r%96s% ' ) T - ) N / - ) 6 / - E E
+ 7 - ) N
3% 0a3 )::+E// 4O+ (O++E/'ON:EN(E&
1 7 - ; - 1 29) ! 6 5 . ) + ) 7 N )
* ) + ! 2 1 W ) + : ! 6 O / < 5 E
. ) ( 7 / I : E ! ' O N N 5 + !
* 5 N T 5 + 'in (ode& = 2 2 1 2
3% 0"3 TELE'-ONE NO% WIT- /T: (O:E
6O.ILE NO% 73>?1==7;
% :)TE O4 .I+T- & :: 6 6 ,,
=% )*E 0)s on 30%0;%20133 & _______23___ com#$eted years%
?% ')+TI(5L)+/ O4 4EE/ 0:emand :raft3
Name @ )ddress of
issuinA .an19.ranch
:ra8n in favour of :ate of
Issue
:: No% )mount
0)##$ication fees shou$d "e sent in the form of :: favourinA B CiDaya .an1 - +ecruitment of
'eons- 2013-1 B and #aya"$e at VIJAYAWADA (ash! 6oney Order! 'osta$ /tam#s9#osta$
orders 8i$$ not "e acce#ted%
'LE)/E )44IE
,O5+ +E(ENT
')//'O+T /IFE
'-OTO*+)'-
)N: /I*N
)(+O//
7% IN:I()TE ., 6)+7 IN )''+O'+I)TE .OE&
i3 *EN:E+& 6)LE 4E6)LE
,E/ NO
ii3 )re you a 8ido8G
,E/ NO
iii3 a3 )re you an E2-serviceman&
"3 In case of E2-serviceman9(ommissioned Officer9'o$ice Officer9
Other EHuiva$ents! s#ecify
1% :ate of discharAe& __________________
2% +an1 at #resent9$ast he$d )3 )ctinA________ 8%e%f%_______
.3 /u"stantive______ 8%e%f%______
O( -I CI
iv3 /5.-()TE*O+, 5N:E+
'E+/ON/ WIT- :I/).ILIT,
0Indicate "y mar1 in a##ro#riate "o2%3
v3 )re you a candidate 8ho is ordinari$y "einA domici$ed in 7ashmir :ivision
durinA the #eriod 01%01%1;>0 to 31%12%1;>;% ,E/ NO
vi3 Whether chi$dren9fami$y mem"ers of those died in 1;> riots &
,E/ NO
vi3 Whether you "e$onA to 6inority community & ,E/ NO
If yes! #$ease state the re$iAion& __65/LI6__________
vii3 In case of /(9/T9O.( (andidate
a3 Name of the (aste9Tri"e9($ass & _____________
"3 Name of the state to 8hich I "e$onA & _____________
viii3 6arried95nmarried &
>% E6'LO,6ENT EE(-)N*E +E*I/T+)TION N56.E+ @ N)6E O4 T-E
E6'LO,6ENT EE(-)N*E&__________________________if any%
;% 4)T-E+I/9-5/.)N:I/ N)6E 0indicate a##ro#riate$y3&
6r% ')T-)N ) * J ) + ) L I 7-)N
10% N)TION)LIT, & ____IN:I)N______
11% 'L)(E O4 .I+T-& '$ace _(-E+575')LLI :ist%_*5NT5+_____
/tate__)N:-+)'+):E/-_____
12% 'E+6)NENT )::+E//&
2
17 - ; - 129) 6 5 . ) + ) 7 N ) * )
+ 2 1 W ) + : 6 O / < 5 E / I
: E ' O N N 5 +
* 5 N T 5 + 'in (ode& = 2 2 1 2
13% E:5()TION)L <5)LI4I()TION
04rom CIII /tandard on8ardsK as on 30%0;%20133&
E2amination
'assed
Name of the Institution
studied
6onth @ ,ear
of #assinA
LaAe of
mar1s
//( 65NI(I')L -I*-
/(-OOL
6)+(--200? 7;%=
INTE+
6E:I)TE
E:5()TION
7/J (OLLE*E 6)+(--200> ?=%7
0If s#ace is not sufficient! #$ease attach se#arate sheet3
1% ')+TI(5L)+/ O4 EE'E+IEN(E! I4 )N,&
Name of the em#$oyer
@ nature of activities
carried "y them
'eriod of
/ervice
4rom To
LenAth of
/ervice
Nature of
duties
#erformed
+emar1s
0+eason
for $eavinA
service3
,ears 6onth
0If s#ace is not sufficient! #$ease attach se#arate sheet% (o#ies of a##ro#riate certificate
to "e attached3%
1=% LanAuaAes 1no8n & 0Indicate "y mar1 in a##ro#riate "o23
0)3 ___EN*LI/-______ +ead9Write9/#ea1
0.3 _______-IN:-I ___ +ead9Write9/#ea1
0(3 ___TEL5*5 ______ +ead9Write9/#ea1
0:3 __________________ +ead9Write9/#ea1
1?% :etai$s of disci#$inary #roceedinAs and &
#unishment! if any! im#osed in the course
of em#$oyment "y the em#$oyer
3
17% )ny other information & ________________________________
D0CLARATION
I here"y dec$are that a$$ the statements made in this a##$ication are true! com#$ete and correct
to the "est of my 1no8$edAe and "e$ief% I understand that in the event of any information "einA
found fa$se or incorrect at any staAe or not satisfyinA the e$iAi"i$ity criteria accordinA to the
reHuirements of the re$ative advertisement! my candidature9a##ointment is $ia"$e to "e
cance$$ed9terminated% I aAree that .an1 has riAht to transfer me to any #art of the /tate at its
discretion% I here"y aAree that any $eAa$ #roceedinAs in res#ect of any matter0s3 or c$aims or
dis#utes arisinA out of this a##$ication and9or out of said advertisement can "e instituted "y me
on$y in VI1A2A3ADA" I underta1e to a"ide "y a$$ the terms and conditions mentioned in the
advertisement Aiven "y the .an1%
'L)(E& ______________
:)TE & _____________ *IGNAT4R0 OF T50
APPLICANT
