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PLACE OF SAFETY, ROURKELA
APPLICATION FORM
ERSONAL DETAILS _
Application for the Concerned — = Affix Recent
sel tested
Posts
(Separate applications for
specific posts)
| Color
Photograph
“Applicant's name (IN BLOCK a ;
| LETTERS) |
‘Address for Correspondence |
Phone Number ]
Date of Birth es Sex | Ma Marital | Unmarried
ODM YIN) (tick) Female | Status | Married
: : | Tick
Caste Nationality:
pesape ove es aelenaene ak en fe Mest nt eae ete
Mother's Name | Father's Name |
Educational Details Attach Photocopies of Certificate and marksheets
| Qualification Name of the | Durati | Subject’ percentage | Full time/ |
Qualification | From | To | College’ | Specialization | / Grade/ time/ |
Awarded | University Division | Bistanes
learning
Under Metric (only
for the post of Cook!
Helper’
| House Keeper)
Secondary (Matriculation)
igher Secondary Sic cs
Education (+2)
Graduation
Post-Graduation | Any other professional) ] |
course / Training related to |
child rights and its
protection or MPhil, PhD) | |
ote, |
Employment Details (Previous) attach Self-Started Photocopies of Experience Certificate
Name of the Designation Key
Organization responsibilities
o Handled
Current Employment Attach Proof of Current Employment
Responsibilities | Working From Monthly Salary
‘Name of the Designation
Computer Literacy
Details of exposure Proficiency
Ability to write
Language Ability to converse
English
Hindi
Odia
Others Referees of two person to whom you have reported professionally in the recent past, whom we
immediately approach for your reference
Referee-1 Referee-2
Name
Address
Organization 5
Designation
Phone/Mobile
E-Mail ID
Your Professional
Relationship
with the Referee.
Declaration-
I do hereby declare that the foregoing information is correct, genuine and correct to the best of my
Knowledge and belief and nothing has been concealed or distorted in it.
Further, it is declared that, I have never been involved in any criminal activities especially in child related
offences and no police case has been lodged me in the past. If anything found contrary to above declaration,
my candidature will be rejected and I will be liable for disciplinary action.
Place:
Date: Full Signature of the Applicant
Note: Applicants also need to fill up the application online via link: https://forms.gle/I HGjafPopW2TQeBS8&
