APPLICATION FORM FOR TEMPORARY ATTENDER Name in FULL (in CAPITALS) Village/Town Taluk/Tehasil District State Contact No. Date of birth (with proof) Category (Tick _/) Whether you are an exServiceman (Yes or No) Whether you are a Physically Disabled Person (Yes or No) Martial Status Nationality Educational Qualification acquired as on date (copy of certificate to be enclosed) Language known

Pin Code Telephone

Mobile No. Gender Male Female SC ST OBC OBC If yes, no. of years of Date of service in Defence Service discharge If yes, nature of Disability Percentag visual, Orthopaedic, e of Hearing Impairment disability Single Married Widowed Divorced Religion

Read Write Speak 1. Name and address of the employment exchange

Whether your name has been Registered with Employment Exchange. If so, furnish details & copy of the certificate to be enclosed) Registration with employment exchange is mandatory Enclosures: 1. Copy 2. Copy 3. Copy 4. Copy 5. Copy

2. Registration No. allotted by the employment exchange and Date

(Please tick mark) of of of of of

Educational Qualification. Caste Certificate (where ever applicable) Employment Exchange Registration. Date of birth certificate/proof Medical Certificate (where ever applicable)

I, hereby declare that the above statements are true, complete and correct and also that no facts have been suppressed. Further, if the furnished information given by me is found to be false or incorrect at a later date, my candidature is forfeited. Place: Date:

SIGNATURE

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA This is to certify that Sri/Smt/Kumari ……………………………………………………………………………. son/daughter of ……………………………………………….. of village/town …………………………………. in District/Division ………………………………………………in the State Union Territory ……………….. Belongs to the ………………………………………………… Community which is recognized as a backward class under the Government of India, Ministry of Social Justice and Empowerment’s Resolution No……………………………… dated …………………………. Sri /Smt/Kumar ……………………………………… and / or his/her family ordinarily reside(s) in the ………………………….District/division of the …………………………………………..State/Union Territory. This is also in certify that he/she does not belongs to the persons/sections (Creamy Layer) mentioned in column 3 of the Schedule to the Government of India. Department of Personnel & Training (I.M 36012/22/93) Estt(SCT) dated 08.09.1993** Date:

District Magistrate / Deputy Commissioner etc.

Seal * The authority issuing the certificate may have to mention the details of Resolution of Government of India, in which the caste of the candidate is mentioned as OBC. ** As amended from time to time. Note: the term “Ordinarily” used here will have the same meaning as in Section 20 of Representation of the People Act, 1950.