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APPLICATION FORM

( for the posts of Shift Engineer in Modern Rice Mill)

Please affix recent


Post applied for SHIFT ENGINEER passport size phot here

Advertisement No. and Date

Name of the Candidate


1
(IN BLOCK LETTERS)
2 Gender (Tick in relevant Box) Male

3 Date of Birth Date Month Year


Age as on 1st July of the year 2018
4
(in completed years)
5 Father's Name

6 Mother's Name
Marital Status
7 Married Ummarried
(Tick in relevant Box)
Spouse Name
8
Husband / Wife
9 Place of Birth
10 Native District and State
11 Mother Tongue
12 Other languages known
Nationality
13 Indian Others
(Tick in relevant Box)
14 Religion (Please specify)
15 Address for Communication

Door No. Street:

City/ Village: District:

State: Pincode:
16 Permanent Address:

Door No. Street:

City/ Village: District:

State: Pincode:
Communal Category
17 OC BC MBC SC SC(A) ST DNC
(Please tick in relevant box)
18 Name of the Sub-caste
a Community Certificate No.
b Date of Issue Date Month Year
c Issuing Authority
d Name of the Taluk: Name of the District:

Medium of Name of the Year of Total Marks Grade/


19 Educational / Technical Qualification %
Instruction Institution passing Marks secured class

a S.S.L.C.

b H.S.C. (+2)
Diploma in Engineering (Mechanical
c
/ Electrical)
d Others

e Experience

Name and
address of the Designation Scale of Pay From
Institution
Details of Present Employment if
20
any

Details of conviction/ Punishment /


21
Disqualification / Criminal case,
disciplinary proceedings etc., if
22 Mobile No. / Phone No.

23 E.mail address

24 Declaration:-
I hereby, declare that all the particulars furnished in this application are true, correct and complete to the best
of my knowledge and belief. In the event of any information being found false or incorrect or eligibility being detected
at any stage, action can be taken against me by TNCSC.

Date:
Place: Signature of the Candidate
Encl.: 1) Self attested Xerox copies of Certificates
2) Recent Passport size photograph 2Nos.
\\192.168.100.11\ho1\sr\ESTT\AE15\appointment\SE 2018\[Application-2019.xls]S.E.