26/09/2019 Andhra Pradesh Grama/Ward Sachivalayam

Antecedent Form

Personal Details

VSWS HallTicket Number 190314006088

Applicant Name TULASI VEMU

Post Applied Ward Educa on & Data Processing Secretary

Date Of Birth of Applicant 10/06/1984

Mobile 8790124466

Religion HINDU

Community SC

Community Sub Caste Mala, Mala Ayawaru *

Place Of Birth Repalle

District To Which Belong GUNTUR

Mar al Status MARRIED

Spouse Name DANDI VENKATA SHYAM PRASAD

Place of Birth Of Husband/Wife Visakhapatnam

Present District VISAKHAPATNAM

A-12 B BLOCK SAI AOK DALE APARTMENT,GAYATRI NAGAR 4TH
Present Address
LINE,P M PALEM,GVMC (Visakhapatnam),530041
Permanent District VISAKHAPATNAM
A-12 B BLOCK SAI AOK DALE APARTMENT,GAYATRI NAGAR 4TH
Permanent Address
LINE,P M PALEM,GVMC (Visakhapatnam),530041

PRECEEDING RESIDENTIAL DETAILS

From To Police Station

Sl.No Residential Address
Month/Year Month/Year & District

FLAT A-12, B BLOCK, SAI OAK DALE APARTMENTS, GAYATRI P M PALEM,

1 09/2018 09/2019
NAGAR TH LINE, P M PALEM, VISAKHAPATNAM -530041 VISAKHAPATNAM

FLAT A-12, B BLOCK, SAI OAK DALE APARTMENTS, GAYATRI P M PALEM,

2 09/2017 09/2018
NAGAR TH LINE, P M PALEM, VISAKHAPATNAM -530041 VISAKHAPATNAM

FLAT A-12, B BLOCK, SAI OAK DALE APARTMENTS, GAYATRI P M PALEM,

3 09/2016 09/2017
NAGAR TH LINE, P M PALEM, VISAKHAPATNAM -530041 VISAKHAPATNAM

FLAT A-12, B BLOCK, SAI OAK DALE APARTMENTS, GAYATRI P M PALEM,

4 09/2015 09/2016
NAGAR TH LINE, P M PALEM, VISAKHAPATNAM -530041 VISAKHAPATNAM

FLAT E7, B BLOCK, SAI OAK DALE APARTMENTS, GAYATRI P M PALEM,

5 09/2014 09/2019
NAGAR TH LINE, P M PALEM, VISAKHAPATNAM -530041 VISAKHAPATNAM

Father Details

Father Name V CH YESUPADAM

Profession/Job No
VISAKHAPATNAM
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Postal District
A-12 B BLOCK SAI AOK DALE APARTMENT,GAYATRI NAGAR 4TH LINE,P M PALEM,GVMC
Postal Address
(Visakhapatnam),530041
Permanent District VISAKHAPATNAM
A-12 B BLOCK SAI AOK DALE APARTMENT,GAYATRI NAGAR 4TH LINE,P M PALEM,GVMC
Permanent Address
(Visakhapatnam),530041

EDUCATION QUALIFICATION DETAILS

Examination Police
Name Of School/College Entering Leaving
Course RegNo & Passed Station &
Address Date Date
Details District

ST. JOSEPHS GIRLS HIGH

SSC/Matriculation 04/1998 03/1999 0205175 GUNTUR
SCHOOL, GUNTUR

ST.JOSEPHS GIRLS JUNIOR

Intermediate/Diploma 09/2019 09/2019 8124519 GUNTUR
COLLEGE, GUNTUR

Graduation/Professional RVR AND JC COLLEGE OF

10/2001 06/2005 Y1IT876 GUNTUR
Course ENGINEERING

NALANDA INSTITUTE OF
Post Graduation ENGINEERING AND 10/2009 09/2011 09A71D5832 SATTENAPALLI
TECHNOLOGY

Any other Qualification --- --- --- --- ---

Case Details

Is Arreted By Police.convicted by Court Of Law Under any

No
state/central Laws

Have you ever been arrested No

Have you ever been prosecuted No

Have you ever been kept under deten on No

Have you ever been bound down No

Have you ever been fined by a Court of Law No

Have you ever been convicted by a court of Law No

Have you ever been debarred from any examina on or

rus cated by
No
any university or any other educa onal
authority/ins tu on

Have you ever been debarred /disqualified by any Public

Service
Commission/Staff Selec on Commission/or any other No
recruitment
board for any of its examina on/selec on

Is any case pending against you in any court of law at

No
the me of filling up this Antecedents form

Is any case pending against you in any University or other

educa onal
No
authority/ins tu on/ at the me of filling of this
Antecedents Form?

Whether discharged/expelled/with drawn from any

training/ins tu on under No
the Government or otherwise?

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RESPONSIBLE PERSON DETAILS

First Preference Second Preference

Name in Full Sur Name SUDHA KAPUGANTI SRAVYA PALLANTLA

Given Name If Any -- --

Fathers Name K RAMA RAO P RAMA KRISHNA

House/Apart/Flat No FLAT 103 SAI TIRUMALA ENCLAVE FLAT NO-101 SRI SAI NILAYAM

Street and Road LALITHA NAGAR THATICHETLA PALEM

Village VISAKHAPATNAM VISAKHAPATNAM

Mandal/Taluk GVMC (Visakhapatnam) GVMC (Visakhapatnam)

Town/City Election Ward 11 Election Ward 11

District VISAKHAPATNAM VISAKHAPATNAM

Pin Code 530016 530016

Urban/Rural URBAN URBAN

DECLARATION DETAILS
1. I hereby declare that the statements made In this form are true to the best of my knowledge and
belief.
2. I am married / unmarried and have only one wife living ( delete which Is not applicable).
3. I am fully aware that furnishing of false Information or suppression of any factual Information in the
Antecedents Form would be a disqualfication and is likely to render me unfit for employment under the
Government.
4. I am also fully aware that If It comes to notice at any time during my service that false Information
has been furnished or that there has been suppression of factual Information in the Antecedents Form,
my services would be liable to be terminated solely on this ground.
Date Signature of the Candidate
Place (Full Name: )

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