Application for Security Assistant (Executive) Examination-2009

PART-I

1. Code and Name of center for written test For office use only
(Refer table ‘A’. Application shall be rejected if
boxes left unfilled) Roll No.
Center Code Center Name Candidate should
affix his/ her recent
2. a) Date of Birth (as per Matriculation certificate) self attested passport
size photograph

Date Month Year

b) Age (As on closing date)

Years Months Days

Signature of the candidate
in box above preferably in
Black ink/ Black ball pen

3. Male/ Female (Write ‘M’ for Male, ‘F’ for female)

4. a) Whether SC/ ST/ OBC

(Write ‘Y’ for Yes, ‘N’ for No)

Category with Code
1 for SC
2 for ST
3 for OBC

5. Whether the resident of J&K and seeking age relaxation

(Write ‘Y’ for Yes, ‘N’ for No)

6. i) Whether Ex-serviceman: Yes/No

ii) Total Service rendered as Ex-serviceman

Years Months Days

7. Home State:……………………………………………………………………….
8. Nationality:………………………………………………………………………..
9. Educational Qualification (Graduation Onwards)
SI Exam Passed Subjects of study Maximum marks Marks obtained %age of marks
No. obtained
1
2
3
10.Previous experience
Period Last pay
Name of the Organization Nature of duties Drawn
Pay Scale
With Designation From To
11. Extra curricular activities:………………………………………………..
12. Languages/dialects known and skill level (Reading-Writing-Speaking)

(i) …………………………………………………………………….
(ii) …………………………………………………………………….
(iii) ……………………………………………………………………..
13. Are you prepared to service anywhere in India: (Write Yes/No)

14. Name in Full:

15.Father’s Name:

16.Mailing Address

Pin Code

17.Permanent Address:

Pin Code

I hereby declare that I satisfy the conditions of the eligibility advertised for admission for the examination.
All the information made in this application are true to the best of my knowledge and belief. I am aware that
if at any time, it is found that any information given above is false or incorrect then my candidature is liable
to be cancelled.

Place: Signature of the Applicant

Date:
 PART-II
To be filled by the Head of Office in which the candidate is serving.
(Only for Government Employees)
It is certified that:
i) There are no circumstances rendering Shri/Ms………………. unsuitable for appointment as
Assistant Central Intelligence Officer Grade-II /Executive
ii) He/ She is regularly appointed as ………………………… with effect from ………….. and
continues to be so employed
iii) He/ She is permanent (state designation) ……………………….. of the (Name of the Department
etc.)……… with effect from ……………. and continues to be so employed
iv) The information given be Shri/Ms…………. in the application has been verified with reference to
his/ her service record and is correct
v) No disciplinary proceeding is pending or contemplated against Shri/Ms……………

OFFICE SEAL:…………………………. SIGNATURE:…………………..

NAME:………………………….
DESIGNATION:……………….
DEPARTMENT/ OFFICE…….
Admission card
IB’s Assistant Central Intelligence Officer Grade II (Executive) Examination-2009

1. Name of the Candidate :…………………………………………..

Candidate
(To be filled in by the Candidate) should affix
his/her
2. Roll Number:………………………………………………………
recent self-
(For Office Use Only)
attested
3. Date, Time and Center of Examination- See Annexure
passport size
(For office use only) photograph
Assistant Director
Subsidiary Intelligence Bureau
(Ministry of Home Affairs)
Government of India

To
Name:……………………………………..
Address:………………………………….
(To be filled in by the candidate)

Note:
1. Please attach a self-addressed un-stamped envelop of 10x23 cm size
2. This admission card should be of the size of 30x21cms. No deviation from the size indicated will be
accepted
3. You will not be allowed admission in the examination hall if you fail to bring this admission card.