PROFORMA FOR APPLICATION
Recent
To, Passport
Commandat sizephoto
ASC Centre (South) - 2 duly self-
ATC Post: Agarm attested
Bangalore - 560007
1. Post applied for : …………………………………………………….
2. Name of the Candidate (Full Name) : …………………………………………………….
3. Mobile Number (Functional) : …………………………………………………….
4. E-mail ID : …………………………………………………….
5. Aadhar No. : …………………………………………………….
6. Father's Name : …………………………………………………….
7. Date of Birth (As per education certificate) : ……………………………………………….
8. Correspondence Address :-
House No/ Street/ Village : …………………………………………………………....
Post Office : …………………………………………………………….
District : …………………………………………………………….
State : …………………………………………………………….
Pin Code : …………………………………………………………….
9. Permanent Address :-
House No/ Street/ Village : …………………………………………………………….
Post Office : …………………………………………………………….
District : …………………………………………………………….
State : …………………………………………………………….
Pin Code : …………………………………………………………….
10. Educational Qualification : …………………………………………………………….
(Metric/ITI/Diploma/12th/
Graduation/Post Graduation
11. Educational Qualification
Ser Qualification Name of Name of % of Marks Remarks
No. School/College Board/University
12. Gender (Male/Female/ Other) : ……………………………………………
13. Category (UR/ SC/ST/ OBC/ : ……………………………………………
EWS/PH/ ESMI MSP)
14. If applied for the post of Ex-Serviceman : …………………………………………....
(Date of enrolment in Army/ Navy/ Air Force
and date of retirement and attach copy
of Discharge Book/ certificate/ NCO)
15. If applied for the post in PH category :-
Type of Disability (OH/HH/ Percentage of Disability (O Pop- Remarks
VH/ Mental Illness/ up menu for 40% and above)
Multiple disability)
16. Whether registered with any : …………………………………………….
employment exchange
(If yes, mention registration No.
and Name of employment exchange)
17. Whether employed in Central Govt Services : Yes/ No
(If yes, give details as per following format)
Name of employer Office Address Name of Post Date of Appointment
18. Name of ASC Depot/ Units, a candidate wishes to be posted, if selected in the order
of preference :
(a) 1st Choice : …………………………………………….
(b) 2nd Choice : …………………………………………….
(c) 3rd Choice : …………………………………………….
DECLARATION
I herby certify that above particulars mentioned in the application are correct and true to
the best of my knowledge and belief. I understand that in the event of any information
being found false or incorrect at any stage or not satisfying the eligibility criteria
according to the requirements of the advertisement, my candidature/ appointment is
liable to be cancelled/ terminated. I am willing to serve anywhere. I agree that
department has the right to transfer me to anywhere in India.
Dated : …………..….. (Signature of the Candidate)
Place : .......................
Enclosures:-
(i) Two Self-Attested Photographs (Name & father's name on the back side of photo).
(ii) One self-addressed registered envelope duly affixed with appropriate postal stamps.
(iii) Self-Attested copies of certificates ( ) Sheets.
Appendix – I
Government of ...........................
(Name & Address of the authority issuing the certificate)
INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY
WEAKER SECTION
Certificate No. : ...................... Date : ………….....
VALID FOR THE YEAR……………………
1. This is to certify that Shri /Smt / Kumari............................................ son/daughter/wife
of ………………………………. Permanent resident of ............................................... Village/
Street …………………………. Post Office ………………….. Pin Code ……………………
whose photograph is attested below belong to Economically Weaker, since the gross
annual income * of his/her "family"** is belong Rs. 8 lakh (Rupees Eight Lakh only) for
the financial year ............................... His/her family does not own or possess any of the
following assets***
I. 5 acres of agricultural land and above.
II. Residential flat of 1000 sq. ft and above.
III. Residential plot of 100 sq yards and above in notified municipalities;
IV. Residential plot of 200 sq. yards and above in areas other than the notified
municipalities.
2. Shri/Smt/Kumari ………………………. Belong to the ..................................... caste which
is not recognized as a Scheduled Tribe and Other Backward Classess (Central List).
Signature with seal of Office ……………………….
Name ………………………………….
Recent Designation …………………………..
Passport size
attested
photograph of
the applicant.
* Note 1: Income covered all sources i.e. salary, agriculture, business, profession etc.
** Note 2: The term “Family” for the purpose includes the person, who seeks benefit of
reservation, his/her parents and siblings below the age of 18 years as also his/her
spouse and children below the age of 18 years.
*** Note 3: The property held by a “Family” in different location or different places/cities
have been clubbed while applying the land of property holding test to determine EWS
status.
Appendix-II
FORM OF UNDERTAKING TO BE GIVEN BY CANDIDATES APPLYING
FOR CIVIL POSTS UNDER EX-SERVICEMAN CATEGORY
I understand that, if selected on the basis of the recruitment/ examination to
which this application relates, my appointment will be subject to my producing
documentary evidence to the satisfaction of the appointing authority that I have
been duly released/retired/discharge from the Armed Forces and that I am
entitled to the benefits admissible to Ex-Servicemen in terms of the Ex-
Servicemen (Re-employed in central Civil Services and Posts) Rule, 1979, as
amended from time to time.
I also understand that I shall not be eligible to be appointed to a vacancy
reserved for Ex-Servicemen in regard to the recruitment covered by this
examination, if I have at any time prior to such appointment secured any
employment on the Civil side (including Public Sector Undertaking Autonomous
Bodies/Statutory Bodies, Nationalized Banks, etc.) by availing of the concession
of reservation of vacancies admissible to Ex-Servicemen.
Place : ………………….. (Signature of Candidates)
Date : …………………….
Appendix-III
DECLARATION BY OBC CANDIDATES ONLY
(Similar endorsement should be given by the caste certificate from the competent
authority)
“ I …………………………… Son/Daughter/Wife of Shri ………………………..
Reidence …………………………… of Village/Town/City ……………………..………
District …………………………….. State....................................... hereby declare that I
belong to the.................................. Community which is recognized as a backward class
by the Government of India for the purpose of reservation in service as per order
applicable to concerned State. It is also declared that I do not belong to
persons/sections (Creamy Layer).
Place : ………………….. (Signature of Candidates)
Date : …………………….
ADMIT CARD (IN DUPLICATE)
1. Name of candidate : ………………………………………………. Recent
2. Father’s Husband’s Name : …………………………..………….. Passport
size attested
3. Date of Birth : …………………………………………....………… photograph
4. Post applied for : ………………………………………………...… of the
applicant.
5. Category (UR/SC/ST/OBC/EWS/PH) : …………………….……
Signature of Candidate
ADMIT CARD (IN DUPLICATE)
1. Name of candidate : ……………………………………………… Recent
Passport
2. Father’s Husband’s Name : …………………………….……..… size attested
3. Date of Birth : ……………………………………………………… photograph
of the
4. Post applied for : ……………………………………………..…… applicant.
5. Category (UR/SC/ST/OBC/EWS/PH) : …………………………
Signature of Candidate
