To, 

     The…………………………………………………………………………………..

     Name of Post ……………………………………………………………………                                     PHOTO

     Department / Office ……………… …………………………………………. 

1. Name in Full (Block letter)                                         :………………………………………………………..

2. Present Address                                                           : …………………….. Vill/Twon………………… 

3. Permanent Address                                                     : ……………………… Vill/Twon………………… 

4. Father’s Name & Address                                           :………………………………………………………..

5. Place of birth including                                              :……………………………………………………….

 Police Station and District & P.O                                   ………………………………………………………..

 6. Are you a citizen of india and if so how? (Copy of citizenship certificate should be enclosedwhere necessary ) 

                                                                                            :………………………………………………………. 

7. Educational qualification and also the name and full address :…………………………………………….

8. Other Qualifications                                                      :………………………………………………………. 

9. Community                                                                    :………………………………………………………. 

(a) State your religion                                                        :………………………………………………………. 

(b) Are you a member of Schedule                                    :………………………………………………………. 

Caste/Schedule Tribe (Answer ‘Yes’ or ‘No’) If ‘Yes’ give particulars supported by a certificate copy of which should be enclosed. 

10. Age on the 1st January 20…. (According to H.S.L.C certificate copy of which should be enclosed)                                                                                             :………………………………………………………… 

11. Present occupation (if any)                                        :………………………………………………………….. 

12. Previous appointment held (if any)                            :…………………………………………………………. 

13. Are you a temporary or retrenched personal of Temporary Departmental of the Govt. of Assam (Answer ‘Yes’ or ‘No’) State particulars                                                                                                                                                                                                :…………………………………………………………. 

14. Are you trained in or a member of the National Cade Crops of Territorial Army or trained Home Guards and Civil Defence Volunteers, if so give particulars                                                                                                                                                                   :…………………………………………………………. 

15. Employment Registration No.                                     :…………………………………………………………. 

16. Whether there is any Govt./Semi Govt. Employees in your family if any, Particulars of such family member like relationship, name of the job, pay drawn, place of posting, permanent /Temporary etc. should be furnished. 

                                                                                                 :…………………………………………………………. 

17. Family’s income certificate from                                      :…………………………………………………………. 

the Gaon Panchayat /DC/SDO/Circle Officer to be furnished 

18. Examination Centre                                                         :…………………………………………………………. 

       I am a candidate for the post ……………………………………………….. and the stated above are true to the best of my knowledge and behalf. In case of any false statement, I am liable to any action the Government deem fit and proper.

       A treasury challan of Rs ……………………… is attached herewith. 

19. To be filled in by Candidate

 Date: ………………

 Place ………………                                                                                                   Signature of Candidate