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ON-LINE APPLICATION FOR OFFICER SCALE III, II & I AND OFFICE ASSISTANT

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Please paste your recent passport size photograph and sign across it. Please retain atleast 5 copies of same photograph with you for subsequent use.

Registration # : Full Name: Category : Name of the Post Applied : If Physically Challenged : Type of Disability : Percentage of Disability :

25248 PAWAN KKUMAR SC Officer Scale-I NO -

Do you intend to use the services of a scribe (only for NA VI & OC candidates whose writing speed is affected by cerebral palsy)? Are you candidate who had ordinarily been domiciled in Kashmir NO Division of the State of J&K during the period 1-1-1980 to 31-12-1989? : Whether you belong to Religious Minority Community? : Religion to which you belong : Are you an Ex-Serviceman? : Are you a disabled Ex-Serviceman : Are you a Dependent of an Ex-Serviceman (DXS)? : Are you seeking relaxation under widows/divorced women/women judicially separated from their husbands and who are not remarried. : Nationality : Domicile Of Uttar Pradesh : Centre of Examination : Centre code : Application Fee / Postal Charges Details : Payment In : Journal No : Branch Name : Branch Code number : Deposit Date : Amount : State Bank of India 013698865 Khorabar 14900 20-06-2011 100 NO -NO ---India YES Gorakhpur 11

Personal Details : Date of Birth: Age completed as on 01.04.2011 : Gender : Father's Name / Husband's Name : Mother's Name : Address for Correspondence : 05-11-1989 21 MALE BRIJBHAN SAROJ INDRAWATI DEVI Block Colony Khorabar Gorakhpur

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District State : Pin : Permanent Address : Gorakhpur UTTAR PRADESH 273008 Block Colony Khorabar Gorakhpur District State : Pin : Contact Details: Phone No : Mobile No: Email ID : Qualification Details (as on 01.04.2011): Exams Passed Graduation : Professional : Working Knowledge of Computers : Details of Computer Knowledge : Subject/stream Information Technology Others Year of Passing 2011 2011 YES OCA % of Marks 65.00 90.00 Class / Grade First Class First Class 9307810001 pkrajwanshi2009@gmail.com Gorakhpur UTTAR PRADESH 273008

Post Qualification work experience details as on 01.04.2011 (Start from present Employee): Name of the Employer Designation From(mm/yyyy) To(mm/yyyy) Length of Nature of Reason for Leaving Service Duties Performed (YY/MM) Total Relevant Experience (in months) : Other Details : Would You like to undergo Pre-Exam Training (SC/ST/Minority Community/Ex-Serviceman) If Yes Centre for Training : Languages Known Hindi English YES Gorakhpur Read YES YES Write YES YES Speak YES YES -

DECLARATION:
I hereby certify that the above information furnished is correct to the best of my knowledge and belief. I have not suppressed any material fact or factual information in the above statement. I am aware that in case I have given wrong information or suppressed any material fact or factual information or I do not satisfy the eligibility criteria according to the advertisement, then my candidature will be rejected/ service terminated even after permanent employment without giving any notice or reasons thereof. I hereby certify that I am satisfying the eligibility criteria for the post applied for in terms of advised criteria in respect of age, caste, educational qualification etc. I hereby agree that any legal proceeding in respect of any matter or claims or disputes arising out of application or out of said advertisement can be instituted by me only at Gorakhpur and courts/ Tribunal/ forums at Gorakhpur only, shall have sole and exclusive jurisdiction to any cause/ dispute. I undertake to abide by all the terms and conditions in the advertisement given by the Bank.

Place: Date: 24-06-2011 Signature of Applicant

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PAWAN KKUMAR
Please retain your Registration No. and Password emailed to you carefully for further reference