Paste here your ASSAM PUBLIC SERVICE …

1 ASSAM PUBLIC SERVICE COMMISSION ** application form for Combined Competitive (Main) Examination, 2016 Last Date for submission of application form 15/12/2017 Date of Receipt: ../../2017 Roll No. of (Pre) Examination 2016: Examination fee: Rs. 150/- for SC/ST(P)/ST(H) and Others Rs. 300/- only through treasury receipt. Name of the Treasury No. & Date of Treasury Receipt Amount Do you claim any fee concession? If yes, mention SC/STP/STH Yes No IMPORTANT INSTRUCTION: (1) PLEASE READ THE INFORMATION AND THE INSTRUCTIONS TO CANDIDATES CAREFULLY BEFORE FILLING UP EACH ITEM BELOW (2) The following information is to be filled in by the applicant neatly in English only with BLACK BALL POINT PEN ONLY (3) Paste the Passport Photograph in the Box with gum or glue and do not Staple (4) Do not make any stray marks on this form (5) Application not signed by Candidate shall be rejected. 1.(a) Name of the candidate: (b) Present Address (IN BLOCK LETTERS) : For Communication Road/Bye lane/Ward No.

2 :..House No., if 2. (a) Father s/Husband s Name (IN BLOCK LETTERS): .. (b) Mother s Name (IN BLOCK LETTERS) : .. 3. Permanent Address (IN BLOCK LETTERS) : Road/Bye lane/Ward No.:..House No., if Paste here your recent passport size photograph. Do not staple. Sign in the space provided below (in Capital letters as per Matriculation Certificate) Advt. No. 19/2016 Page - 2 4. Gender: (Tick in the appropriate box) : Male Female 5. Date of Birth (Enclose a copy) : (DD/MM/YYYY) (as per Matriculation or equivalent examination) 6. Age on 01/01/2016 : .. (s)..Day(s) 7. Are you eligible for age relaxation? : Yes No 8. Nationality : .. 9. Mention clearly to which category you belong.

3 SC/ST(P)/ST(H)/OBC/MOBC(a self attested copy of certificate issued by the appropriate authority in support of your above claim must be enclosed) 10. Are you a Person with Disability : Yes No (a) If yes, give particulars : VI OH HI (b) Degree of Disability in % (certificate from the Competent authority must be enclosed) : .. 11. Previous occupation, if any : .. 12. Are you employed (Tick ), if employed : Yes No Submit an Employment certificate (self declaration) 13. Present occupation, if any (describe briefly) : .. 14. Particulars of all examinations passed : .. Commencing with Matriculation or equivalent Examination Examination passed Class or Division Percentage of Marks Year Subjects Name of School/College Name of Board/ University Page - 3 15. State according to your choice any two : Optional subjects given in the Syllabus for Combined Competitive (Main) Examination : (No subsequent change of such subject shall be allowed) 16.

4 State in order of preference of the following : Services and posts for which you would like to be considered for appointment. (The choice of Preference exercised once is final and no change shall be allowed) (A) (Jr. Grade), (B) ASSAM Land & Revenue SERVICE (Jr. Gr.) (C) ASSAM Police SERVICE ( ) (D) Labour Officer (E) Superintendent of Taxes (F) Asstt. Registrar of Cooperative Societies (G) Inspector of labour (H) Inspector of Taxes (I) Inspector of Excise (J) Asstt. Employment Officer Choice of Preference 17. Are you debarred from any examination and/or : .. Selection conducted by the UPSC or any State PUBLIC SERVICE Commission (Answer Yes or No ) 18. Are you debarred from applying for any Govt. : .. Post (Answer Yes or No ) 19. Give name (s) and particulars of two respectable : .. Persons of status (not related to you) from whom You should attach self attested copies of certificates.

5 Of recent time relating to your character. Page - 4 I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. In the event of any information being found false or incorrect or ineligibility being detected before or after the examination, action may be taken against me by the Commission as may deem fit. I have read the terms and conditions of the Commission as published in the advertisement for Examination, 2016 carefully and I hereby undertake to abide by them or/and any other terms and conditions as may be applicable to me. I further declare that I fulfill all the conditions of eligibility regarding age limits, educational Qualification etc. prescribed for admission to the examination. I have informed my Head of Office/Department/Employer (Where applicable) in writing that I am applying for this examination. Place.

6 Date : .. Signature of Candidate (in full)