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Registration EE_CNV_Act & Rule

PROFORMA FOR REGISTRATION IN EMPLOYMENT EXCHANGES HARYANA Registration No. : 2011660608

1. First Name : Middle Name : Last Name :

2. Gender: Male Female 3. Marital Status : Widow Divorcee by Husband 4. Father / Husband First Name : Middle Name : Last Name : Unmarried Legally Separated Married Deserted

5.

Date of Birth (DD-MM-YYYY) :

6. Category : BC Category

GEN PH EXM

SC

ST

7.

If Physically Handicapped and getting PH Allowance :

8. Religion : Christian 9. Postal Address :

Hindu Bhuddhist

Muslim Other

Sikh

House No./ Street/ Sector State Village/ City/ Town Distt. Tehsil

10. 11. 12. 13.

Phone/Contact No.(with STD code): Mobile No: E-mail Address, if any : Examination Passed / Professional Qualification (See Code List): Roll NO Board/Univ. Year Of Passing

Examination Passed Matric

Sr. No Examination Passed Board / Univ. Year of Passing Subjects / Durat ion of Diploma Marks obtained / Total %age / Grade Science / Arts / Commerce / Subject of Specialization in case of higher or professional studies (5,6) 1. Below Matric /

2.

Matric

3.

10+2 / 2 Years Diploma

4.

Graduation / 3 Years Diploma

5.

Post graduation

6.

If any other Qualification

(Please mention your academic qualifications information starting with M atriculation if the qualification is above Matric, otherwise mention qualificati on as applicable.) 14. Expected Salary (Per Month):

15. Work Location Preferred : Distt. State India Overseas 16. (I) Preferred Job Type : (II) Preferred Job Type : (III) Preferred Job Type :

17 Preferences (a.) May tick one or both : Govt. Job Private Job Interested in Loan for Self Employment (b.) Whether willing for :- daily wages/D.C rate/ less than 6 month/ part time job : Yes No 18. 19. 2. 3. 4. 5. Any Special Skills acquired : Areas of Skill Development Required/ Preferred :: 1.

20. Yes

Do you have Passport ?:

21.

Languages Known : Read Write Speak

Sr. No Languages 1. Hindi

2.

English

3.

Punjabi

4.

22.

Work Experience :

Sr. No Name/address of Organization with Telephone No. Designation From (DD -MM-YYYY) To (DD-MM-YYYY) No. of Month(s) Sector Salary per month (Rs.) 1.

2.

3.

23.* yes No

Are you currently working any where?

The above information has been read by me / read out to me and I certify that th e above information is true and nothing has been concealed. In case any informat ion is found to be concealed / incorrect my registration may be cancelled. Registration Date:

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