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Advertisement No.

7599
dated 28/04/2015

Application form
No .
(for office use only)

Application form
Part A
(On Contract / On Deputation)

Recent coloured
P.P. size photo
graph attested by
self

1. Name of the post (Applied for) :


2. Post code no.
: .
(i.e. s. no. of post in advertisement)
3. Name of applicant
:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name)

(Surname)

4. Father's name

5. Permanent address

(Name)

(Surname)

PIN.
6. Present address

:
PIN.:.
(Address proof : Enclosure 1)

7. Date of birth

:. . . . /. . ../ . . . . . . . (In words .. . . . . . . . . . . . . . . . . . . . .)

(Attested true copy of marksheet of Higher Secondary School Certificate Examination /equivalent
examination exhibiting date of birth : Enclosure 2)
8. Age as on the date of Advertisement : Years Months . Days
9. Category (Please tick)

: Unreserved/ OBC/ SC/ ST

(Self attested true copy of caste certificate in case of OBC/SC/ST candidate : Enclosure .3)
10. Home district

11. Educational qualification details :


(1) Post Graduation

: Degree . . . . . .. .. . Specialisation in .

(2) Graduation

: Degree . . .. . . .. . . .Subject

(3) Others (Diploma etc.)

: Description . .. . .. . . . . . . . . . . ..

12. Service and experience details :


(a) Parent Department
: .
(b)

Details of organization : .

(c)

If working, then, present Post :. .


1

(d)

If retired, then, name of the post from which retired :.

(e) If working then address of the present office:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . ....


(f)

Designation at first posting :. . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(g)

If working, then present pay :. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..


(As per present applicable pay rules)
(e.g. pay in the pay band and grade pay in revised pay structure)

(h)

If retired, then last pay details

: . . . . . . .. . . . . . . . . . . . . . . . . . . . . .

(i)

Present basic pay :. Rs. . . . . . .. . . . . . . . . . . . . . . . . . . . .


(e.g. pay in pay band + grade pay, in revised pay structure)

(j)

Post wise experience in bridge work (as on date of publication of advertisement)


:. . . . . . Years . . . . .Months . . . . . Days.

(k)

Post wise field experience in bridge work (as on date of publication of advertisement)
(Wherever applicable)

(l)

:. . . Years . . . . .Months . . . Days.

Total length of service (as on date of publication of advertisement)


:. . . . . . ..Years . . . . .Months . . . . . Days.

12. PAN (if available)


(Attested true copy: Enclosure . . . .)

: ..

13. Cell phone no.

: ..

14. Email ID

: ..

(Signature of applicant)
Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . .

Declaration
I hereby declare that no criminal proceedings of any nature is pending against me. I further
declare that information supplied by me in, the application form and its supplementary parts and
enclosures annexed to it; are true to the best of my knowledge & belief. My selection to the post may be
cancelled and suitable action may be taken, if information furnished by me in part A, B, C and D is found
false or incorrect at any point of time in future.
(Signature)

Date :. . . . . . .. .
Place :. . . . . . .. .

Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . .

Encl Part B,C and D of the application


along with enclosure 1 to .

Advertisement No.
7599
dated 28/04/2015

Application form
No .
(for office use only)

Part B
(On Contract / On deputation)

1. Name of the post (Applied for) : .


2. Post code no.
: .
(i.e. s. no. of post in advertisement)
3. Name of applicant

:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. .
(Name)

(Surname)

4. Father's name

5. Present address

(Name)

(Surname)

PIN.:.
(Address proof : Enclosure 1)
6. Date of birth

:. . . . /. . ../ . . . . . . . (In words .. . . . . . . . . . . . . . . . . . . . .)

(Self attested copy of mark sheet of Higher Secondary School Certificate Examination /equivalent
examination exhibiting date of birth : Enclosure 2)
7. Age as on date of advertisement : Years Months . Days
8. Category (Please tick)

: Unreserved / OBC / SC / ST

(Self attested copy of caste certificate in case of OBC/SC/ST candidate : Enclosure ..)
9. Home district

10. PAN (if available)

: .

(Attested true copy : Enclosure . . . .)

(Signature of applicant)
Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . .

Advertisement No.
7599
dated 28/04/2015

Application form
No .
(for office use only)

Part C
(On Contract / On deputation)

1. Name of the post (Applied for) :


2. Post code no.
: .
(i.e. s. no. of post in advertisement)
3. Name of applicant

:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. .
(Name)

4. Father's name

(Surname)

:
(Name)

(Surname)

5. Educational qualification details :


(1) Post Graduation

: (i)

Degree . .. . .. . .. . . Specialisation in

: (ii)

Name of institution

: (iii)

Year of passing

: (iv)

Percentage of marks/CGPA

(Enclosure.)
(2) Graduation

: (i)

Degree . .. . . .. . . .. Branch

: (ii)

Name of institution

: (iii)

Year of passing

: (iv)

Percentage of marks/CGPA

(Enclosure.)
(3) Others (Diploma etc.)

: (i)

Description

: (ii)

Name of institution

: (iii)

Year of passing

: (iv)

Percentage of marks/CGPA

(Enclosure....)

(Signature of applicant)
Name of the applicant: . . . . . . .. . . . . . . . . . . . . . . . .

Advertisement No.
7599
dated 28/04/2015

Application form
No .
(for office use only)

Part D
(On Contract / On deputation)

1. Name of the post (Applied for) :


2. Post code no.
: .
(i.e. s. no. of post in advertisement)
3. Name of applicant

:. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .
(Name)

4. Father's name

(Surname)

:
(Name)

(Surname)

5. Service and experience details :


Name &
S.
full
No. address of
employer

Designation
At first
posting

As on
today

Brier
description
of work

Salary
(In Rs.)

Period of
employment
From

To

Place
of
posting
(office/
field)

6. Field experience on present post (as on date of publication of advertisement :.


.. . . Years . . . . .Months . . . Days.
7. Total length of service (as on date of publication of advertisement)

:.

. . . . . ..Years . . . . .Months . . . . . Days.


8. Name of authority, competent to provide NOC and its address : ..
....
9. Whether NOC has been enclosed or not ? : .
(For deputation only)
10. Details of any two construction works which you would like to mention
Designation

Period from . to ..

Details of work
executed

Approx cost of executed work


in Rs .Lakhs

(Signature of applicant)
Name of the Applicant: . . . . . . .. . . . . . . . . . . . . . . . .
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