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Lok Sabha Secretariat Recruitment 2015 Format To Fill

Application Form

Roll No.

PARLIAMENT OF INDIA

(To be filled in by JRC)

(JOINT RECRUITMENT CELL)


****
APPLICATION FORMAT

Affix recent selfattested passport


size Photograph

Advt. No. 1/2015

Name of the Post applied for: Security Assistant Grade-II

1. FULL NAME (In Capital Letters):


Signature of Candidate
First Name
Middle Name
Surname
(Please leave one box blank between each part of name)
2. FATHERS NAME (In Capital Letters): _________________________________________
3. MOTHERS NAME (In Capital Letters): ________________________________________
4. NATIONALITY: ______________________
5. ADDRESS FOR COMMUNICATION: _________________________________________
_______________________________________________________PIN__________________
6. DETAILS OF RESIDENCE DURING LAST 5 YEARS WHERE THE APPLICANT HAS
RESIDED FOR MORE THAN ONE YEAR:
ADDRESS

PERIOD OF STAY

7. PERMANENT ADDRESS: ___________________________________________________


_________________________________________________________PIN________________
8. DATE OF BIRTH:
D D
M M
Y E
(Please enclose self-attested copy of
--the certificate)

9. a. Date of first appointment in Army/Navy/Air Force:

M M
--

Y
--

b. DATE OF discharge:
(Please enclose self-attested copy of relevant pages
of Discharge Book/certificate)

D D

M M
--

Y EA R
--

10. PLACE OF BIRTH (Village/Town/City/District/State):___________________________________


11. AGE AS ON 05.05.2015: Years_______ Months_______ Days_______
12. CATEGORY (Gen/SC/ST/OBC):__________________________
(The candidates belonging to SC/ ST/OBC must enclose self-attested copy of the certificate as a proof)

13. DETAILS OF EDUCATIONAL, PROFESSIONAL & TECHNICAL QLFNS.


(Please enclose self-attested copies of the certificates)
(a) Educational:
Exam
Institution/
Subjects studied
Medium Duration Year of % of
Passed
University
of
of study passing marks
Instruction

(b) Professional/Technical (Please enclose self-attested copies of the certificates)


Exam
Passed

Institution/
University

Subjects studied

Duration
of study

Year of
passing

% of
marks

Division
obtained

14. DETAILS OF EXPERIENCE/SERVICE (Please enclose self-attested copies of the certificates)


(a)
GOVERNMENT DEPARTMENTS/OFFICES
Name of
Govt. Orgn.

Post held

Pay
Scale*

Duration of service (Exact


dates to be given)
(From - To)

Whether
regular or
not

Nature of duties
performed

* Please indicate Grade Pay also, wherever applicable.

(b)

IN OTHER ORGANISATIONS (Please enclose self-attested copies of the certificates)


[Name of
Orgn.

Status of organisation
[Government/PSU/Private, etc.]

Post
held

Pay
Scale*

Duration of service

(From To)

* Please indicate Grade Pay also, wherever applicable.

Whether
regular or not

Nature of duties
performed

15.

DETAILS OF ACHIEVEMENTS in NCC/SPORTS

Event

Year

Institution/ Organisation

Particulars of
achievement

16.

Do you possess the essential educational qualifications as required for the post applied for?

Yes/No

17.

Do you possess relevant experience prescribed for the post applied for?

Yes/No

18.

DECLARATION

I declare that I fulfil the eligibility conditions as per the advertisement and that all 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
information being found false or incorrect at any stage or not satisfying the eligibility conditions according to the
requirements mentioned in the advertisement, my candidature/appointment is liable to be cancelled/terminated.

PLACE:
DATE:

(SIGNATURE OF CANDIDATE)

Note: Applications without self-attested copies of necessary certificates/documents as


mentioned in column nos. 8, 9, 12, 13 & 14, recent photograph and signature of the
candidate will be summarily rejected and no request/correspondence will be
entertained in this regard.

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