PUBLIC SERVICE COMMISSION, WEST BENGAL APPLICATION FORM

ASSISTANT ENGINEER (CIVIL) RECRUITMENT EXAMINATION, 2013

: The 21 January, 2014

st

full signature thereon.

CAUTION
(i) A candidate must consult the Important Information and Scheme and Syllabus available with advertisement in the Commissions Website, then use the prescribed application format and fill in the application form correctly against all the items in his/her own handwriting with ball point pen of black/blue ink and furnish required particulars/documents.

(ii) Correction/overwriting, if any, should be accompanied by signature of the candidate. (iii) In case the application is not filled in accordance with the above instructions or any of the required documents is not enclosed, it will be treated as incomplete/defective and summarily rejected. (iv) If any item(s) of the application is considered inapplicable to the candidate he/she should write NOT APPLICABLE or (N.A.) against the particular item(s) and in any case no item of the application should remain unfilled. Note :

Keeping the application form in front, the particulars/documents are to be stitched with the application securely with a durable thread in the following sequence (1) I.P.O. or Treasury Challan, in original (not required for SC/ST candidates of W.B. and Persons with Disability), (2) Attested by competent authority or self-attested photocopies of (i) Certificates relating to educational qualification (Madhyamik or equivalent and onwards), (ii) Experience Certificate, if any, (iii) SC/ST/BC/PH certificate (if applicable), (iv) Citizenship certificate (for candidates acquiring citizenship by registration) and (3) Two Unstamped Self-addressed envelopes.

1.

Name of the candidate

: (IN CAPITAL LETTERS)

2.

(a) I.P.O./Treasury Challan attached for (b) I.P.O. No.(s) & Value (c) Date of purchase and name of issuing Post Office with address (d) Treasury Challan No. & Date

: : : :

Rs. _____________________

3.

(a) Community / Category [ Put mark in appropriate box. SC/ST/BC candidates not belonging to the State of West Bengal should indicate their community as General ] (If SC/ST/BC, attach attested or self-attested photocopy of the certificate) (b) If SC/ST/BC Candidate, mention

Gen

BC CategoryA

BC CategoryB

SC

ST

Sub-Caste

State

Issuing Authority

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4.

(a) Whether you are a person with disability (Write Yes or No in the box) (IF YES ATTACH ATTESTED OR SELF-ATTESTED PHOTOCOPY OF CERTIFICATE)

(b) (i) In case you are a person with disability (PWD), state the Category (Put mark in the appropriate box) : Suffering from blindness or low vision Hearing Impaired Orthopaedically Handicapped

(ii) In case you are a person with blindness or low vision, mention if you require the help of a Scribe : Yes (Put mark in appropriate box) D D 5. Date of Birth (as recorded in Madhyamik or equivalent examination Certificate) Do you claim relaxation in upper age, If yes, state reason S E X (Put mark in appropriate box) : M M Y E A R

No

6. 7.

: :

_____________________________________ Male Female

8.

(a) Whether a Citizen of India (Put mark in appropriate box)

Yes

No

(b) Whether a natural citizen or citizen by registration ? : (Put mark in appropriate box) [ If a citizen by registration, attach attested by competent Authority or self-attested photo copy of the certificate] 9. 10. Fathers Name (IN CAPITAL LETTERS) (a) Complete address for communication (IN CAPITAL LETTERS) mentioning locality, Post office, Sub-Divn., Dist. and Pin-Code : : :

Natural citizen

Citizen by Registration

(b) Permanent Address

11.

Educational Qualification (Madhyamik or equivalent and onwards) : [ Attested by competent authority or self-attested photo copies of all certificates must be attached with the application] Name of Examination Year of passing Board / University / Institute % of marks Division/ Class Subjects Taken

12.

Any other relevant information with reference to the Requirement of the post (Attach extra sheet, if necessary)

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(a) (b) (c)

Do you have the ability to read, write and speak in Bengali (Write Yes or No) Whether you are a Nepali Speaking person (Write Yes or No)

: :

i) Whether you are a person from any Hill Sub-Division : of Darjeeling District (viz. Darjeeling Sadar, Kalimpong, Kurseong) ( Write Yes or No ) ii) If yes, mention the name of Sub-division : ______________________________

(d)

State your mother tongue

14. If you have at any time been employed, give details (Attach extra sheet if required) : Name of Post held Office where employed State whether Govt./ Local/ Statutory body or private concern Date of joining Date of leaving Cause of leaving Permanent or temporary or on contract basis Salary PayAllowances

15.

(a) Did you appear previously in the examination for recruitment to the post of Assistant Engineer (Civil), conducted by P.S.C., West Bengal ? Write Yes or No (b) If yes, specify years of examination and roll numbers

Year of Examination

Roll No

16.

(a) Were you debarred previously by the Commission from applying through this Commission for appointment under Government ? (Write Yes or No) (b) If yes, give details

Year

Examination

Roll No.

Debarred upto (Date)

17.

The list of documents enclosed : i) iii) v) ii) iv) vi)

DECLARATION
I solemnly declare that (a) All statements made in this application are true, complete and correct (b) Original documents will be produced on demand (c) I agree to take the examination on the condition that the Commission may cancel my candidature if at any stage I am found ineligible for admission to the examination and (d) I have submitted no other application for this examination. **I have informed the head of my Office or Deptt. in writing that I am applying for this examination (** Strike off this sentence if the candidate is not in service of Govt., or Local or Statutory Body).

Place : Date : Full Signature of the Candidate (in running script)