Affix attested recent passport size photograph

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					                                 APPLICATION

    1.  Name of Post applied for        ___________________
    2.  Name (in block letters)         _______________________________    Affix attested recent
    3.  Father’s Name (in block letters _____________________________         passport size
    4.  Address for Correspondence _______________________________             photograph
        (in block letters)              _______________________________
                                        _______________________________
    5. Permanent Address                _______________________________
        (in block letters)              _______________________________
                                                    _______________________________
    6. Contact No./ Mobile No.                      _______________________________
    7. Date of Birth                                _______________________________
    8. Whether belongs to Reserve Category          _______________________________
        If so specify and attach certificate copy.
    9. Under Which Category applied for             _______________________________
        (Gen/SC/BC/ESM/DESM/ Sports/ SC
        Balmiki Mazhbi Sikh etc.
    10. Nationality                                 _______________________________
    11. Marital Status                              _______________________________
        (Married/ Unmarried)
    12. Sex (Male/Female)                           _______________________________
    13. Have you passed Punjabi up to matric or     _______________________________
        its equivalent standard
    14. Qualifications:

Sr. No.     Examination      Board/     Month & Subjects        Total Marks    Percentage
            Passed           University Year of passed          Marks Obtained of Marks
                                        Passing
1           2                3          4       5               5        6           7

    15. Experience: if any
        (Attach Certificate)                         _______________________________
    16. Gold Medal                                   ________________________________
        if any (proof to be attached)
    17. Publication if National/                     _________________________________
        International Medical Journals
        (proof to be attached)

DECLARATION:
              I, hereby declare that:-
1 (a) All statements made in this application are true, complete and correct to the best of my
      knowledge and belief. In the event of any information being found false or incorrect or
      ineligibility being detected before or after the selection, action can be taken against me by
      the Governement.
(b)   I fulfil all conditions of eligibility as given in the advertisement and other relevant
      instructions.
II    I have informed my head of Office/ Department in writing that applying for this post.

          (Score out II, if not applicable)                         Signature of applicant

Place: _______________
Date: _______________

Enclosures: 1.     ___________________ 2.  ______________ 3. _______________
4.     __________________ 5.   _________________ 6.    _____________________

				
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posted:11/5/2012
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