------------------------------------------------------------------------------------------------------------------------------------------------------ Application for Recruitment to the post of VILLAGE ADMINISTRATIVE OFFICER (Pay Band - 1: `5200-20200 with Grade Pay: `2400/-) 26484 POST APPLIED Name of the Post Code Number VILLAGE ADMINISTRATIVE OFFICER 01 Applicant's Specimen Signature: 1. Application Number : 26484 2. Name of the Applicant : Mr. VIJAY P 3. Father's Name : PACHAIAPPAN R 4. Mother's Name : SAROJA P 5. Spouse's Name (if married) : 6. Date of Birth : 06/09/1985 7. Age as on 22/01/2014 : 28 years and 4 months 8. Gender : Male 9. Address : Address for Communication Permanent Address E-34. VIDUTHALAI NAGAR MUDALIARPET PUDUCHERRY - 605004 E-34 VIDUTHALAI NAGAR MUDALIARPET PUDUCHERRY - 605004 10. Mobile Number : +919677273569 11. E-Mail Id : vijay2_85@hotmail.com 12. Educational Qualifications : Sl. No. Qualification Name of the Board Month & Year of Passing 1 SSLC or equivalent STATE BOARD OF MATRICULATION, TAMILNADU Jun, 2001 2 H.Sc / 3 years Diploma or equivalent STATE BOARD OF SCHOOL EXAMINATIONS, TAMILNADU May, 2003 13. Technical Qualifications : Name of the Course Duration of Course (in Months) Month & Year of Passing Name of the Institution Wether recognized by Government C CPLUS 3 Jun, 2005 SSI EDUCATION Yes 14. Nationality : INDIAN 15. Whether Native / Resident of Puducherry : Yes 16. Religion : HINDU 17. Have Regd in Emp Exchange? : Yes 26484 | 21/01/2014 04:16:19 PM Page 1 of 2 1. 2. 3. 4. 5. 6.
DECLARATION
I have read the provisions in the Notification of the examination carefully and hereby undertake to abide by them.
I declare that I am a Native / Resident of Union Territory of Puducherry by virtue of continuous residence for the last five years immediately preceding the date of Notification and I understand that any deviation in this regard will render my selection invalid.
I have not submitted any other application for this examination. I am aware that if I contravene this, my application will be summarily rejected.
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational qualification, technical qualification etc., prescribed for admission to the examination.
I also declare that I have never been convicted by any court of law. I also declare that no charge sheet is pending against me in any court of law.
I understand that success in examination confers no right to appointment. I further understand that appointment is subject to fulfillment of all conditions stipulated in the Notification.
I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found suppressed / false or incorrect or ineligibility being detected before or after the examination, my candidature / appointment is liable to be cancelled. a. Region : PUDUCHERRY b. Registration No. : 0162182 c. Next Renewal Date : 31/07/2013 18. Community : MBC - Origin 19. Category : Not Applicable 20. Examination Centre : PUDUCHERRY 21. Medium of Examination Opted : ENGLISH and TAMIL 22. Examination Fee : Name of the Bank Amount Demand Draft Number Demand Draft Date STATE BANK OF INDIA `50/- 262912 20/01/2014 23. Ration Card Number : 67388 24. EPIC / Voter ID Number : DNX0430876 25. Certificates : Certificate Name Certificate Number Date Issued Taluk Office PIC ----- ----- ----- Residence / Nativity 17116/top/c/10 20/07/2010 Taluk Office, Oulgaret Caste 17116/top/c/10 20/07/2010 Taluk Office, Oulgaret DATE: 21/01/2014 PLACE: PUDUCHERRY SIGNATURE OF THE APPLICANT Note: Unsigned application will be rejected. 26484 | 21/01/2014 04:16:19 PM Page 2 of 2
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