Application Form - East Khasi Hills

::::::DISTRICT SELECTION COMMITTEE :: EAST KHASI HILLS DISTRICT :::::: S H I L L O N G ::::Free of costAPPLICATION FORM [AF-1]Instructions1. Please fill the Form using a ball point pen.2. Use block letters only.3. Fees as per rate specified in the advertisement (Half rate for ST/SC candidates). The amount may be paid through A Treasury Challan4. You are required to Affix / Attach (i) One recent self attested passport size photograph (ii) Treasury Challan copy with the Application.5. Acceptance of this form by the DSC, East Khasi Hills District does not constitute validity of candidature. Final validity of candidature shall bedetermined at a subsequent stage.6. Read the advertisement for the post in question before filling up the form.INCOMPLETE APPLICATION WILL BE SUMMARILY REJECTED1. Advertisement No. and date :_____________________________________________2. Name of the Post applied for : ___________________________________________________________3. First Name : ___________________________________________________________Middle Name : ___________________________________________________________Surname : ___________________________________________________________Affix latest passportsize photograph ofsize 3.5 x 4.5 cm. Donot staple or Pin.Use Gum only4. Date of Birth : 5. Sex ( Male / Female)(enclose BirthCertificate) (dd) (mm) (yyyy) [Male] [Female]6. Marital Status ( Married / Unmarried ) _______________________________________________________________________7. Father’s / Mother’s Name _______________________________________________________________________8. Father’s / Mother’s Occupation _______________________________________________________________________9. Husband’s Name (for married females) _______________________________________________________________________10. Present Address in full with Pin Code _______________________________________________________________________(This address will be used for allCommunication)__________________________________________________________________________________________________________________________________________________________________________________________________________________11. E-mail Address ______________________________________________________________________12. Phone No. Mobile No. ____________________________ Landline with STD Code _________________________13. Permanent Address in full with _________________________________________________________________Pin Code___________________________________________________________________________________________________________________________________________________________________________________________________14. Are you a resident of Meghalaya ? (Yes / No) _______________________________15. Are you a citizen of India ? (Yes / No) _______________________________

16. Address during the preceding four years :From To Address___________________________ _____________________________ _____________________________________________________________________ ____________________________ _____________________________________________________________________ _____________________________ _____________________________________________________________________ _____________________________ __________________________________________17. Are you a member of SC/ST/OBC ? (Yes / No) __________________________________________If Yes, indicate the Caste/Tribe (enclose certificate)_____________________________________________18. Are you Physically Handicapped ? (Yes / No) ________________ If Yes, specify the P.H. details.Visually Handicapped ____________________Orthopedic Handicapped ________________Hearing Handicapped ________________________Other, Please specify ________________________Enclose: (a) Certificate from Medical Board(b) Certificate of Registration from Employment Exchange19. Have you ever represent the state or country or district ___________________________________________In any discipline or sports ? (Yes/No)If Yes, specify the details____________________________________________________________20. Education Qualifications (in Reverse Chronological Order)SlNo.Name of Institution & Address Board /UniversityExaminationPassedYear ofPassingSubjects Division PercentageObtained21. Additional Qualifications, If any ____________________________________________________________22. Are you a Trained Member of the NCC / TerritorialArmy/ Retrenched Personnel ? (Yes / No) ________________________________________________________23. Languages :-LanguageUnderstandSpeakReadWriteKHASIENGLISHJAINTIAGARO24. Are you presently working with the Government ?(Yes / No)______________________________________________________

25. If Yes, specify the following details :Appointment Type :Name of the Office :Name of the post held :Duration in Months :Permanent Adhoc Casual Contractual__________________________________________________________________________________________________________________________________________________________________________________________________________________26. Present occupation (For Non-Govt./Semi Govt./PSU/Private/Others) :Name of the Organization :Name of the Post held :Duration in months :27. Previous appointment held,(if any, and duration in months)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________28. Have you at any time been debarred fromany examination and / or selection conductedby UPSC/SSC/MPSC/DSC/Others (Yes/No) ___________________________________________________29. Are you debarred from applying for anyGovernment Post ? (Yes / No)___________________________________________________30. Place of Birth :Village / Town ____________________________________District ____________________________________________Police Station ___________________________________State _____________________________________________Declaration :I certify that the foregoing information is correct and complete to the best of my knowledge andbelief. I also understand that my candidature is liable to be cancelled in case of any false statement.Date : _________________________Signature within the boxSignature of CandidateMobile phones and such I.T. Gadgets are banned inside the examination roomFOR OFFICE USE ONLYList of Enclosures :Photo Age Certificate ST/SC CertificateEducational QualificationsAdditional QualificationsFor Physically challenged / PWD candidates onlyHandicapped CertificateCertificate of Registration from Employment Exchange