(THROUGH PROPER CHANNEL FOR CANDIDATES WORKING IN GOVERNMENT & SEMI-GOVERNMENT ORGANIZATIONS

1. (a) Name of the Applicant (in full) ___________________________________

Please affix a

(b) Present or Last Designation held by Applicant (in full)_____________________________

self-attested

photograph

(c)

Organization __________________________________________________

(d)

Office Address __________________________________________________

2. Address for communication ________________________________________________________________

3. Telephone No. : Office ________________________________ Residence ________________________ Fax No. ______________________________ Mobile No. _______________________ E-mail address __________________________________________________________ Date of Birth _____________ Age as on date of issue of vacancy notice ______Years ____ Months Nationality______________

1. Pay and total annual emoluments drawn in the last assignment held:
   
   
2. Eligibility Criteria :
   
   
3. Positions held during the preceding twenty years : -(Chronological start with recent one)
   
   

	Qualification	Institution	Year
Educational / Professional Qualifications (along with the name of Institutions)
(a) Graduation
(b) Post-graduation
( c ) Other qualifications

Sl. No.	Designation & Place of Posting	Organization	From	To	Details of relevant work experience and achievements
1.
2.
3.

4.
5.
6.
7.
8.

7. Certification and Affiliations

Sl. No.	Particulars of Certification	Certifying Body	Date of Issuance	Date of Validity, if any

1. Skills
   
   
2. Job Fitness and Strategic Vision (explain your fitness and your strategic vision in 500 words)
   
   

Sr. No.	Management Skills	Technical Skills

2.

11 (a) Whether any punishment awarded to the applicant during the last 10 years If yes, the details thereof

Yes	No

(b) Whether any action or inquiry is going on against him/her as far as his/her knowledge goes

If yes, the details thereof

Yes	No

I _____________________son/daughter of_________________________ Resident of _______________________ certify that the details furnished by me in Cols. 1 to 11 are true and I am eligible for the post.

Date : (Name & Signature of the applicant)

(To be filled by the PSU/Ministry/Department concerned in case of Candidates working in Government / Semi-Government Organization)

It is certified that the particulars furnished above have been scrutinized & found to be correct as per official records.

Signature & Designation of the

Competent forwarding authority

with telephone no. & office seal

Note: Please attach self-attested copies of proof of

1. Date of birth
   
   
   1. Educational Qualifications
      
      
      1. Graduation
         
         
      2. Post-graduation
         
         
      3. Other qualifications
         
         

(THE INFORMATION RECEIVED WILL BE TREATED AS CONFIDENTIAL)