JHARKHAND PUBLIC SERVICE COMMISSION RANCHI
Recruitment of Registrar (Non-Teaching) in Nilamber Pitamber University, Medininagar, Palamu
(Advt. No- 11/2017)
Registration No. (To be filled in by JPSC):
(All the information should be filled in Block/Capital Letters Only)
1. Name of the post :
2. Name of Applicant :
(In Hindi) :
(In English):
3. Domicile State (Please in the box)?
Jharkhand Others
4. Category (Please in the box)?
UNR BC-I BC-II SC ST
5. Do you claim fee relaxation on the basis of caste (Please in the box)?
Yes No
(Please in the box) SC ST
a) Caste Certificate No: ________________ (Issued by an officer not below the rank of SDO in prescribed format I or II)
b) Caste Certificate Issuing Authority (Please in the box) SDO DM DC
c) Caste Certificate Date of Issue:- DD MM YYYY
6. Gender (Please in the box): Male Female Transgender
7. Marital Status(Please in the box): Married Unmarried
8. Do you claim fee relaxation on the basis of being Handicapped (Please in the box)?
Yes No
if yes,
a) PH Category : ____________________________ b) Percent : _________________
c) PH Certificate No. : _______________________ d) Date : ___________________
9. Date of Birth :- DD MM YYYY (As per Matriculation/10th/ SSE / CBSE/ ICSE/ other equivalent examination certificate)
Age as on 01.08.2017: YY MM DD
Page 1 of 4
10. Correspondence address :
District: State: Pin:
11. Permanent Address :
District: State: Pin:
12. Father /Husband’s Name :
Relationship (Please in the box): Father Husband
13. Mobile No :
14. E-mail ID :
15. Proof of Personal Identification : (Anyone)
(UID/ Voter ID/ Driving Licence/ PAN Card/ Passport/ Other)
16. Personal Identification No :
17. Nationality:
18. Identification Mark :
19. Educational Qualifications :
Education Name of Subject(s) Name Board/ Year of Full Marks % of Class / Certificate No
Degree University Passing Marks Obtained Marks Grade
10th/ SSE
12th/ HS
Graduation
Post
Graduation
Other
( if any)
Page 2 of 4
20. Experience Details : 15 years experience as per clause 3 of the Advertisement.
Si. Name of Name of Post Nature of Post From To Period/ Name of
No. University/College/ (DD/MM/YYYY) (DD/MM/YYYY) Experience Department
Institution (YY/MM/DD)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
21. Whether you are employed with Central Govt. /State Govt./PSU/Public Institution/Organization
(Please in the box) :- Yes No
If Yes,
Name of Post Nature of Post Date of Appointment Date of resignation (if any ) Name of employer
DD / MM / YY DD / MM / YY
DD / MM / YY DD / MM / YY
DD / MM / YY DD / MM / YY
Page 3 of 4
22. Fee Details: Fee amount, as applicable: Rs. : ___________________ + Bank Charges: Rs. 50/-
Total Amount Paid: Rs. : ___________________
Name of SBI Branch : _______________________________________________________________
Journal No: ___________________________ Date: ______________________________________
23. List of enclosures:-Self attested Photocopy of
(Please or X in the box) :-
1) Matriculation Certificate/Marksheet (as proof of age).
2) Graduation Certificate.
3) Post Graduation Certificate.
4) Caste Certificate (if applicable).
5) Documents in support of Experience.
6) NOC Certificate (if applicable).
7) PH Certificate (if applicable).
8) Fee Challan (JPSC Copy in original).
9) Any other required document according to Advertisement.
24. Declaration:-
i) I hereby declare that the above information is true to the best of my knowledge and belief. I have read the
advertisement and its clauses regarding age limit, educational qualification, reservation etc. and there is no false or
incorrect representation of the same. If any of the above information found to be false or incorrect, then my candidature
can be cancelled by the Commission at any stage.
ii) I have already communicated to my Controlling Officer/ Head of Department in this regard (for Govt. Employee only).
NOC issued by the employer will be produced at the time of interview.
iii) I have read the advertisement and I agree to the terms and conditions elaborated in the advertisement.
(3.5cmX4.5cm) Signature (In running hand) :-
Passport Size
Photo :
Photo with Self Date :-
Attested
Place :-
Page 4 of 4
