Code No.:____________
PROFORMA FOR REGISTRATION IN EMPLOYMENT EXCHANGES
HARYANA
PART - I
Please fix your
(To be filled by candidate) Passport Size
photograph
1. Full Name : _______________________________________
(Please mention your name as is in Matriculation Certificate or from other applicable certificate)
2. Gender: Male Female (Please the appropriate)
3. Marital Status : Married Unmarried Widow Divorcee
Legally Separated (Please the appropriate)
4. Father’s Name : ______________________________________
5. Husband’s Name (if Married) : ___________________________
6. Date of Birth (DD/MM/YYYY) : ____/____/________
(Please mention date of birth as in Matriculation Certificate or from other applicable certificate)
7. Category : SC ST BC OBC GEN PH EXM
EBC OFOJ
(Please the appropriate)
(Please mention your Category as per the certificate issued by the competent authority. Without proper certificate applicant will be
considered in the General Category)
8. If Physically Handicapped and getting PH Allowance :
ID _________________ Amount Per Month : Rs.______________
(Mention ID given by Social Justice & Empowerment Deptt.) (Mention amount p.m. given by Social Justice & Empowerment Empower Deptt.)
Type of disability: Ortho. Deaf & Dumb Blind Any Other
(Please the appropriate)
%age of disability : ________%
(Please indicate the %age of disability as mentioned by the Competent Authority in the Medical Certificate)
9. Religion : Hindu Muslim Sikh Christian Buddhist Other
(Please the appropriate)
10. Postal Address:
House No./Street /Sector _________________________________________________
Village/City/Town___________________________________ Block (Code)___________
Tehsil____________Distt.__________ State _______________________
11. Phone/Contact No.(with STD code) .: _____________________________
12. Mobile No.: ___________________
13. E-mail Address, if any : _______________________________________________
14. Examination Passed / Professional Qualification (See Code List):
Sr. Examination Passed Code Board/ Year of %age Science/Arts/ Code Date of
No Univ. Passing Commerce/ Verification
Subject of by the
Specialization in Employment
case of higher Office
or professional (DD/MM/YYYY)
studies (5,6)
1 Below Matric
2 Matric
3 10+2
4 Graduation
5 Post Graduation
6 If any other
Qualification
(Please mention your academic qualifications information starting with Matriculation if the qualification is above Matric, otherwise
mention qualification as applicable.)
15. Expected Salary (Per Month): Rs._______________
(Please mention how much minimum salary you expect)
16. Work Location Preferred : Distt. State India Overseas:
(Please the appropriate)
(Please indicate where you want to work)
17. Preferred Job Type : (Code)_______________________________________________
18. Preference (May tick one or both) : Govt. Job Private Job Interested in Loan
for Self Employment
19. Any Special Skills acquired : (Code) ________________________
(Please mention here if you have any special skills)
20. Areas of Skill Development Required/ Preferred : 1)_______________ 2)_______________
3)_______________ 4)_______________ 5)_______________ (Code)
(Applicant will mention here, in case he / she wants to become employable, the skills he/she wants to attain.)
21. Do you have Passport ?: Yes / No
If Yes, Passport No.:____________ Date of Issue:DD/MM/YYYY Date of Expiry: DD/MM/YYYY
22. Languages Known (Please the appropriate):
Sr.No. Languages Read Write Speak
1 Hindi
2 English
3 Punjabi
4 Other
23. Work Experience :
Sr. Name/address of Designation From To No. of Sector Salary per
No Organization with (MM/YYYY) (MM/YYYY) Years month (Rs.)
Telephone No.
1
2
3
I have read the above information / has been brought to my knowledge and I certify that it is true and
nothing has been concealed. In case any information is found to be concealed, my registration number
may be cancelled and I shall be liable for furnishing false information.
Date: _______________
Name of Employment Exchange: _______________ (Signature of Applicant)
Registration No.________________
Note: Please attach your X-10 card (Registration Card)
Part – II
For Applicants Getting Unemployment Allowance
Please furnish the following details:
1. If, Getting Unemployment Allowance please fill in the following
Date from which getting (DD/MM/YYYY): ____/____/_____
Allowance received upto quarter ending (MM/YYYY): ____/________
Total Amount Received so far : ________________________
Please the appropriate :
Matric / 10+2 (Non Science Subject Boys) / 10+2 (Science Subject Boys) / All 10+2 Girls /
Graduate & above (Non Science Subject Boys) / Graduate Science Subject Boys / Graduate
all Subjects Girls
(Please tick the category in which you are getting unemployment allowance)
Date: _______________
Place: _______________ (Signature of Applicant)
(To be filled by the Office)
Employment Exchange Phonetic Code: _______________________
I. Registration No. : _______________________
II. Date of Registration (DD/MM/YYYY) : ___/_____/______
III. Date of Latest Renewal (DD/MM/YYYY) : ___/_____/______
IV. Recommended Occupation (Recommended by EO): __________________ NCO Code ________
V. Alternative Occupation (1) (Opted by Applicant): _____________________ NCO Code________
VI. Another/2nd Occupation opted by applicant as per his qualification: ________NCO Code________
VII. Family ID.:________________
VIII. Members ID.: _____________
IX. Voter List No.: ____________ (Auto generated in computer)
X. Bank Account No. & Branch Code through which Unemployment Allowance is being disbursed:
Account No: _________________ Branch Code: ________________