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(An Undertaking of U.P. Government)
Photograph Paste 3.5 x 4.5 cm size, good quality recent/latest colour photograph, to be self-attested

APPLICATION FORM Advt. No. U-12/UPRVUSA/2013 Recruitment for Handicapped under Backlog Quota

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Post Code
(Refer List 1)

: :

Post Name :

Name DOB

Age (as on 31.07.2013) Y Y Nationality : Y Y M M D D

Gender Father's Name Qualifying Degree Code (Refer List II) Month & Year of Passing Marks In Percentage of Essential Qualification Course Duration of essential Qualification Correspondence Address

D D M M Y Y : Male (M) / Female (F) : : :


Qualifying Degree : Marital status :

: : : years

(format xx.xx%, do not round)


Pin Code : Email ID . hone No. with STD code P

Mobile No.

: :

Category Code (Refer List III)

Category : Degree of Disability : % (Disability below 40% is not applicable) Organization

Handicapped Category (Code) : (Refer List IV) : Apprenticeship (Yes / No)

If yes Duration of Apprenticeship (in months) :

I hereby declare that I have carefully read the conditions of eligibility mentioned in the advertisement. These conditions are acceptable to me and I fulfill these conditions. The details mentioned in the application are true and I shall furnish the necessary certificates in proof of the above at the time of Interview. If any information/details found to be incorrect/false at any stage of the selection or if any fact is found to have been concealed by me is detected even after the appointment, my services may be terminated.


Thumb Impression

Male (Left) / Female (Right)


Signature of Candidate

Lists List I
Post Code 09 10 11 12 13 14 Name & Branch

List III
Code GN BC SC ST Category General + (OBC,SC & ST of States other than UP) OBC (Non Creamy Layer) of UP SC of UP ST of UP

Assistant Engineer(T)- Electrical Assistant Engineer(T)- Mechanical Assistant Engineer(T)- Electronics Junior Engineer (T)- Electrical Junior Engineer (T)- Mechanical Junior Engineer (T)- Electronics

List II
Assistant Engineer(Trainee) E & M Cadre QD Code Qualifying Degree AA AB AC AD AE AF AG AH BA BB BC BD CA CB CC CD CE CF CG CH CI CJ CK CL CM CN CO CP CQ B.E. (Electrical) B.Tech. (Electrical) B.Sc. Engineering (Electrical) A.M.I.E. (Electrical) B.E.(Electrical & Electronics) B. Tech. (Electrical & Electronics) B.Sc. Engineering (Electrical & Electronics) A.M.I.E. (Electrical & Electronics) B.E. (Mechanical) B.Tech.(Mechanical) B.Sc. Engineering (Mechanical) A.M.I.E. (Mechanical) B.E. (Electronics) B.Tech. (Electronics) B.Sc. Engineering (Electronics) A.M.I.E. (Electronics) B.E. (Electronics & Instrumentation) B.Tech. (Electronics & Instrumentation) B.Sc. Engineering (Electronics & Instrumentation) A.M.I.E. (Electronics & Instrumentation) B.E. (Electronics & Communication) B.Tech. (Electronics & Communication) B.Sc. Engineering (Electronics & Communication) A.M.I.E. (Electronics & Communication) B.E. (Electronics & Telecommunication) B.Tech. (Electronics & Telecommunication) B.Sc. Engineering (Electronics & Telecommunication) A.M.I.E. (Electronics & Telecommunication) Equivalent qualification having Electrical/ Mechanical/Electronics word in their Degree

List IV
Code OA OL PD PB Handicapped Category One Arm affected One Leg affected Partially Deaf Partially Blind

Junior Engineer(Trainee) E & M Cadre QD Code Qualifying Degree DA DB DC DD Diploma in Electrical Engineering Diploma in Mechanical Engineering Diploma in Electronics Engineering Equivalent qualification having Electrical/ Mechanical/Electronics word in their Diploma