OFF LINE FORM

APPLICATION FORM
Post Applied for : ……………………………………………………………………
Affix recent passport
size photograph

Identity should be certified

by an officer as mention in
the advertisement with
designation and seal of
officer

1. Full Name : …………………………………………………………………………………………

2. Father’s Name : ………………………………………………………………………………………..

3. Permanent Address : ……………………………………………………………………...………………..

……………………………………………………………………….………………..

…………………………………………………………………………………………

4. Address for correspondence : ………………………………………………………………………………………

………………………………………………………………………………..………..

……………………………………………………………………………….………….

5. Date of Birth : …………………………………………………………………..……………………..

6. Sex : Male : Female :

7. Religion : ………………………………………………………………………………………..

8. Domicile ( State ) : …………………………………………………….…………………………………

9. Category : Gen. SC. ST. OBC.

10. E- mail Id : ………………………………………………………………………………………….

11. Telephone No. (with std code ) : ………………………………………………………………………………………

12. Mobile No. ( If any) : …………………………………………………………………………………………..

13. Educational Qualification :

Subject Percentage of Year of

Marks Passing
Qualification Principal Subsidiary

14. Experience :

Name of the Designation Nature of Duties Period Duration

Organisatio
n From To

15. If employed in Govt. / PSU, where applied through proper channel : Yes/No.

16. DD No. …………………… Date. ……………………………………. Name of Issuing Branch

…………………………

Declaration : I hereby declare that all statements made in the application are true, complete
and correct to the best of my knowledge and belief. I also undertake that I have not submitted
application for two different posts advertised. The relevant clause is stated below for easy
reference :- “ Candidates can apply against any one post only. Candidates applying for more
than one post will be not considered and such application will be rejected”. I understand that in
the event of any information being found untrue/false/incorrect or I do not satisfy the
eligibility criteria, my candidature. Appointment will be cancelled /terminated, without
assigning any reasons thereof. I have read contents of the advertisement and agree to abide by
the rules, regulations and procedures for appointment to the post of applied for.

Date :

Place : ( Signature of Applicant )

 IDENTITY CERTIFICATE

Affix Photograph

Seal of office & Signature

of the office attesting this
certificate should appear
on the Photograph.

This is to certify that the details and photograph of Shri ………………………………………………………….

S/o …………………………………………………………………..……………………………… and resident of ( R/O )

……………………………………………………………………………………………………………………………………………..

Who has applied for the post of ………………………………………………………….……………………………… is

Verified and certified as correct and genuine.

PERMANENT ADDRESS :

………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………

PRESENT ADDRESS :

………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………

Signature of the candidate : ……………………………………………………………………………….

Signature of the Certifying Officer : ………………………………………………………………………………

Name of Certifying Officer : ………………………………………………………………………….......

Phone No. of Certifying Officer : ………………………………………………………………………….......

Designation ( Seal Of Officer ) : ………………………………………………………………………….......

{ Note : Identity of the candidates should be certified by an officer not bellow the rank of
Tahsildar/Sub-divisional Officer of the candidate’s domicile place/native place, principal of the
school/college from where the candidate as passed as 10th standard, Intermediate or
Graduation/Diploma along with name, Designation and seal of Office.}
 UPNHM

Date …………………………

Name …………………………………………………………………… Post ……………………………………………………

Thumb impression must be filled in front any authorized Grade 1 or 2 officer.

Signature Left Thumb 1 Signature Right Thumb 1

Signature Left Thumb 2 Signature Right Thumb 2

Signature Left Thumb 3 Signature Right Thumb 3

Signature Left Thumb 4 Signature Right Thumb 4

Signature Left Thumb 5 Signature Right Thumb 5

Signature of Authorized Officer Signature of Employee