To The General Manager, Ordnance Factory, Itarsi (M.P.

) Sub: Application for the post of _______________________________________ (Name of the post to be mentioned) Ref: Advertisement No.___________________________ Date_______________

Recent Passport size Photograph duly self attested partially on application and partially on the photograph

1.

Name of the applicant as per Matriculate Certificate : _____________________________________________ (In Capital Letters) Fathers Name: ______________________________________________________________ Sec (Male/ Female): ___________________________ Date of Birth: _________________________________ Age as on the last date of receipt of application: _________________________________ Whether belongs to SC/ST/OBC ______________________________________________ (Mention the category & enclose attested copy of certificate from a Gazetted Officer. OBC certificate should include Non-Creamy Layer clause) Educational qualification (10th onwards) Sl.No Name of Examination Name of Board/University

2. 3. 4. 5. 6.

7.

Year of passing

Division and Percentage

Remarks if any

8.

Measurement of physical standard for Fireman, Durwan. (a) Height without shoes____________(in cm) (b) Chest (Un expanded)_____________ cms. (c)Chest (Expanded)_________________cms. (d)Weight_________________________kgs. Details of Firefighting coursefor Fireman: Name of the Training Institute

9.

From

To

Certificate No. and date

10.

Whether Ex-Serviceman, if yes, please furnish the detail and enclose copy of discharge certificate: Date of Entry in Date of Discharge No. of Year service Any other relevant Information Armed forces rendered

11.

Whether PHP, if yes, furnish following details and enclose copy of disability certificate: Whether, VH, HH Type of disability (B,OL,BL,PD or Percentage of Certificate No. & date or OH D etc.) Disability

12.

Whether employed in Govt./PSU etc, if yes, furnish following details: Name of Organisation/ Nature of work, Emoluments being Department Designation paid

Date from which employed

Permanent or Temporary

13. 14. 15. 16.

Whether resident of any Hilly area (Yes/No) ______________________ Indian Postal Order No./ Demand Draft No._____________________________________________________ Nationality: ________________________________________________ Permanent Address: _______________________________________________________________________ ______________________________________________________________ Pin code__________________

17.

Present Address for communication:__________________________________________________________ ______________________________________________________________Pin code___________________

18. 19. 20. 21. 22. 23. 24.

Nearest Railway Station: ______________________________________________________ Medium of Examination (Hindi/ English) _________________________________________ Religion: ___________________________________________ Phone No./ Mobile No.________________________________ E-mail, ID, if any______________________________________ Any other essential detail ______________________________ Left Thumb Impression

Declaration I do hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found suppressed/ false or incorrect or ineligibility being detected before or after the test/interview my candidature/ appointment is liable to be cancelled.

Date __________2012 Signature of the candidate

Declaration for OBC candidate only I ________________________________ S/D/W/of Shri_________________________ resident of Village/ Town/ City _________________________District_________________ State_____________________ hereby declare that i belong to the _____________________community which is recognised as a backward class by the Government of India for the purpose of reservation in services as per orders contained in Department of Personnel and Training Office Memorandum not belong to persons/ sections (Creamy Layer) mentioned in column 3 of the Schedule to the above referred office memorandum date 08/09/1993 and instruction issued from time to time in this regard. Date: 2012 Signature of the candidate

Undertaking for Ex-Serviceman Only I understand that, if selected on the basis of the recruitment/examination to which this application relates, my appointment will be subject to my producing documentary evidence to the satisfaction of the appointing authority that i have been duly released/retired/discharge from the Armed Force and that I am entitled to the benefits admissible to Ex-serviceman in terms of the Ex-serviceman (Re-employment in Central Civil Services and Posts) rules, 1979, as amended from time to time. 2. I also understand that I shall not be eligible to be appointed to a vacancy reserved for Ex-serviceman in regard to the recruitment covered by this examination, if I have at any time prior to such appointment, secured any employment on the civil side (including Public Sector Undertaking, Autonomous Bodies/Statutory Bodies, Nationalised Banks, etc) by availing of the concession of reservation of vacancies admissible to Ex-serviceman. Date: 2012 Signature of the candidate

List of enclosures: (1) Age Proof Certificate (2) Mark sheet of 10th or equivalent examination (3) SC/ST/OBC/PHP/Ex-serviceman certificate (4) Indian Postal Order/DD of Rs.50/- for General and OBC candidates (5) Tow extra passport size photographs (6) Copy of Fire Fighting Certificate (7) Other documents.

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