PROFORMA FOR APPLICATION

Affix recent Passport size Photograph & sign across it

FOR OFFICIAL USE Registration No. Date of Receipt: ------/------/------Advertisement No. RR Site/HRM/02/2011
1. Name of post 2. Name in full (in block letters) 3. Fathers/Husbands Name 4. Date of birth (in Christian Era) 5. Sex 6. Nationality 7. Religion 8. Marital Status 9. Applicants Category :__________________________Discipline/Branch:_________________ : Name in Hindi Name in English

: ____________________________________________ : : Male : Indian : Hindu : Married : GEN OBC No HH Female Other Muslim Sikkh Christian Buddhist Others 1 9

Unmarried SC ST

10. Do you have any disabilities : Yes 11. If yes, define types of disabilities 12. Educational Qualifications : Examination Passed SSC (10TH Std.) HSC (12th Std.) Year of passing : PH

If yes, indicate percentage of disabilities VH

University / Board / Institute

Percentage of Marks obtained in Science Maths

Aggregate Percentage

13. Technical Qualifications: Examination Discipline/ Passed Branch Diploma in Engineering

Duration of course

Year of admission

Year of passing

University / Board / Institute

Percentage of marks obtained

14. Correspondence Address in block letters

Plot / House No. Gali/Street/Mohalla/Colony................... Sub City/Nagar Post Office .. PIN Code . Village / Town/ City ............ Via ..Tehsil . District . State .

15. Permanent address in block letters

Plot / House No. Gali/Street/Mohalla/Colony ................. Sub City/Nagar .. Post Office .. PIN Code . Village / Town/ City ............ Via ..Tehsil District State

16. E-mail ID of applicant 17. Contact Numbers

: __________________________________ : Land Line No. with STD Code Mobile Number : Yes : Yes No No

18. Do you belong to Ex-servicemen 19. Do you have registered your name in Employment Exchange? If yes, please indicate Registration number & Name of Employment Exchange.

: Registration No. :Name of Employment Exchange State

20. Do you have any close relative employed in NPCIL ? : Yes If yes, give the following details. Sl.No. Name Relationship Unit

No Post

21. Do you have any work experience of working in Central/State Govt./PSUs, Autonomous body or private institute ? if yes, give the following detail : Sl. No. Name of Central/State Govt./PSU/Autonomous body/Private Institute Period From To Total service Post held Detail of work responsibilities

22. Are you under any contractual obligation to serve the Central/State Government/any other Public Sector Undertakings/Autonomous Bodies? If yes, please furnish full details : __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 23. Do you have ever served in Central (including Defence) / State Government/ Public Sector Undertakings / Autonomous Bodies and received / is in receipt of any pension, gratuity or employers share to the provident fund ? If yes, please furnish full details: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 24. List of documents attached :1. 2. 3. 4. Marks sheet or Certificate of SSC for date of birth Marks sheets/Certificate of educational qualifications Professional / technical qualification Certificates/Mark sheets Caste Certificate issued by Competent Authority of State/Central Govt. in respect of applicant belongs to reserved category. 5. Experience certificate issued by the Company/Inst. in respect of applicant having working experience. 6. Disability Certificate issued by District Chief Medical Officer in respect of applicant suffering from disabilities. 7. Discharge Certificate from Army in respect of applicant belongs to EX-Serviceman category. DECLARATION I hereby certify that the above stated information is factually correct to the best of my knowledge and belief. I have not suppressed any information and in case I have given wrong information or suppressed any fact, then my services are liable to be terminated without giving any notice or reasons thereof. I am not aware of any circumstances which might impair my fitness for the above assignment. Place :______________ Date :______________ _____________________________ Signature of the Applicant