APPLICATION FORMAT (To be filled by the candidate in his/her own handwriting in capital letters with black pen) I hereby

apply for the post of __________________ (Advertisement No .HMRBPL/HR/P5/2012/II)

Candidates to affix recent passport sizecolourPhoto graph

Sign here (in the box)

1 Name of the Candidate (As recorded in the Matric/ Secondary School Certificate) Parents Name

Postal Address for Communication (with PIN Code No.) P I N Email id Contact No. (Telephone with STD code / Mobile No.) Date of Birth Day Month Year

4 5

6 Age as on 01.08.2012 7 8 9 10 Gender (Please Tick) Category (Please Tick) PWD/Ex. Serviceman (Please tick, if applicable) State of Domicile 11 Nationality YEARS . MONTHS MALE FEMALE SC PWD ST OBC GEN

Ex. Serviceman

12

Religion

13ALL EDUCATIONAL QUALIFICATION (MATRIC/CLASS 10thONWARDS): Qualification : (Academic, Technical, Professional & Computer related, if any) Name of Board / Institute Duration of Course (in years) Month and Year Joining the course Passing the course % of Marks Obtained

14. DETAILS OF EMPLOYMENT, IF ANY Name & Address of Employer Post Held Period of Service From To Salary perMonth

15. DETAILS OF APPLICATION FEE. Demand Draft No. Name of Issuing Bank Date of Issue

I hereby declare that I have read all the conditions mentioned in the advertisement and I fulfill the same. The 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 particular or information given herein being found false or incorrect, my candidature is liable to be cancelled and in the event of any misstatement/discrepancy in the particulars being detected after my appointment, my service is liable to be terminated without any notice to me. Date: . Place: . Signature Note: 1. The application must accompany the following documents (no other certificate to be attached): a. Attested copies of Matric, Diploma in Engineering Marks sheets and Certificates. b. OBC certificate issued by Competent Authority in the prescribed format c. Experience certificate (if any) 2. Application received after due date would be summarily rejected .