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To
The Executive Officer
Zilla Parishad,
Burdwan

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› eserved for those specified in Advt. No. 3/2010)
2.? Name of the candidate ›in Block letter):-

___________________________________________________________

3.? Father's / Husband's name:-

_____________________________________________________________________

4.? Date of birth:


________________________________________________________________________________
›According to Madhyamik or equivalent examination certificate)
5.? Age ›as on 1.1.2010):-

_________________________________________________________________________

6.? Nationality :-

_________________________________________________________________________________

7.? Postal address in full:-


_________________________________________________________________________
›mentioning P.O., Sub-Division, District & Pin-Code)
_________________________________________________
8.? Whether citizen of India ›write yes or no) :-

_________________________________________________________

9.? Educational Qualification:-

______________________________________________________________________

_____________________________________________________________________

10.? Employment Exchange :-› egs. No., If any)

_______________________________________________________

11.? Whether SC/ST/OBC:-

________________________________________________________________________

12.? Sub-Caste ________________________________________________________________________________


__
13.? Ability to read, write and speak in Bengali
__________________________________________________________
›write yes or no)
14.? Whether physically disabled:-
___________________________________________________________________
›write yes or no & if yes, specify the category of disability)
15. ? whether experienced _________________________________________________________________
›If yes, specify the area of experience)

DECLA ATION
I hereby declare that ›a) all statements made in this application are true, complete and correct to the best of my
knowledge and belief and in the event of any information being found false my candidature is liable to be cancelled. * ›b)
›only of candidates serving under Govt. / Statutory body A Govt. undertaking) I have informed my head of office/
Department in writing that I am applying for this post
* Strike out if not applicable.

Signature of the candidate in full

N.B:- In support of age / caste / physical disability / educational qualification / EC/experience ›if any) necessary certificate
& documents duly attested by competent authority are to be furnished with the application.

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