USEBLACKBALLPOINTPENONLY

WHILEFILLINGUPTHEFORM
HOWTOAPPLY(INSTRUCTIONS TOCANDIDATES)
(Detachthispagewhilesubmittingtheapplicationform)

1. The Candidates should carefully go through the terms and conditions of the advertisement,particularly (i)
Educational qualification (ii)Agelimitand(iii)Experience whereexperience isnecessary.
2.Onlythose candidates whofulfillalltheterms and conditions oftheadvertisement inrespect ofthepost for
whichtheyareapplicants shallbeentertained. Othersneednotapply.
3.TheamountofExamination feesif specifically askedin theAdvertisement shallbedeposited bythe
candidate through treasury challanonly.
4.(i) All candidateswhether in GovernmentService or in Governmentowned undertakingor other similar
organizations/Corporations/Boards/Bodies or in private employmentsmay submit their applicationdirect to
the Commission subject to fulfilling the condition at item No.15 ofthe application form. Ifanysuch candidate
forwardshis/herapplication throughhis/herControlling Officer/Employer, he/sheshouldensurethat the
application reaches theAssam Public Service Commission within theclosing date, failing which itisliable tobe
rejectedevenifithadbeensubmitted totheControlling Officer/Employer beforetheclosingdate.
(ii) The Commissionshall in no way be responsiblein the event of any candidateafter appointmentis not
released bytheconcerned authority toenablehim/her tojointhenewpost.
5. Any candidate in service of the State Govt. of Assam claiming age relaxation in terms of the Personnel (B)
Deptt. OM bearing No. ABP.513/79/9 dated 27.3.1980 and No.ABP.73/89/17 dated 04.01.1992 must submit
the recommendation to the Commissionwithin one month from the last date fixed for submissionof form.
However, theymustsubmit theirdulyfilledapplication withinthetimespecified. Anyrecommendation
received aftertheaforesaid dayshallnotbeentertained andtheapplication shallberejected.
6.Applications mustbeaccompanied byselfattested copiesoftheundermentioned documents, which
shouldbetagged wellwithout anychanceofgettinglostontransit.
Applicationswhich are not accompaniedby anyone of the under mentioneddocumentswill not be
entertained.
(I) Copiesofalleducational certificates andMarksheetsfromMatric/HSLC onwards.
(II) AgeproofCertificate issuedbytherespective Board/University.
(III) Experience Certificates (wherenecessary) indicating theperiodofService/Experiencewithdates.
(IV)Copy/Copiesof originalTreasuryChallanas proof of depositingexaminationfees wherever
necessary aspertermsofadvertisement containing detailsofpostapplied for.
(V) All documents/certificates and other testimonialsmust be attested by the candidateswith his/her
ownsignature.
7.The candidates shall have toproduce identity proof like Pan Card, Driving License, current IDcard issued by
educational Institutions, VoterIDCardatthetimeofWrittenTestandVivaVoce Interview.
8.Thecandidates should visittheCommissions website www.apsc.nic.in offandon.IftheCommission
decides toholdwritten/screening test,thesyllabus willbeuploaded onlyintheAPSCwebsite.
9.Theeligible candidates shallhavetodownload theattendance certificates/call letters fromtheAPSC
website.

ASSAMPUBLICSERVICECOMMISSION
APPLICATION FORM

Pastehereacopyof
yourrecentpassportsize
photograph ofsize
3.5 cm4.5 cm & Sign in
theboxbelow.

ADVERTISEMENT NO121PSC/DR5/3/20132014
NAMEOFTHEPOSTANDDEPARTMENT APPLIED FOR:
BlockdevelopmentofficerunderPanchayat&RuralDevelopmentDeptt.
1.NameoftheCandidate infull:
(INBLOCKLETTERS)
(AsperHSLCcertificate)

DHIRAJTALUKDAR

2.SEX:MALE/FEMALE : MALE
3.Fathers nameinfull :

PHANIDHARTALUKDAR

4.Mothers nameinfull :

MAMANITALUKDAR

5.Present address forcommunication:

#101,JPSQUARE,LAKSHMAIAHREDDYLAYOUT,ST.THOMAS
TOWNPOST,KACHARKANAHALLI,BANGALORE560084,
KARNATAKA.

6.Permanent address :
(If the permanentaddressis sameas
that of presentaddress,pleaseput a
tickmarkonly)

C/OPHANIDHARTALUKDAR,POBARAMA,BAGSADIST.
ASSAM781346

7.Nationality : INDIAN
8.Mention the caste you belong to :GENERAL
SC/ST(P)/ST(H)/OBC/MOBC/GEN.
Pleaseticktheappropriate box.
NOTE:ATTACHSUPPORTINGDOCUMENTS

(ExceptGEN)

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9.IfExServiceman mention
Personal number: Notapplicable
Rank : Notapplicable
NameofService : Notapplicable
Period ofService : Notapplicable
DateofRetirement/Release

: Notapplicable

( Attachcopyof dischargecertificate/Ex
Servicemen IDCard)

10. Do you belongto anycategoryof :Notapplicable

PWD? If so, please tick the
appropriate box.
NOTE:ATTACHSUPPORTINGDOCUMENTS

11. DateofBirth(inChristian era):

26/11/1984

st

12. Ageon1 January 2015

(AsperHSLCorequivalent Exam.)

:30years,1months,and6days

NOTE:ATTACHSUPPORTINGDOCUMENTS

13.
(A) Particulars of the prescribed
Degree/DiplomaExams passed as per
advertisement.
(i) Name of Degree(s)/Diploma(s) : BscComputerscience,BharathidasanUniversity,Trichy
Passed, Name of College/Institution/ 2006,72%
University/Boardfrom which you have
passed,yearofpassing &P.C.of
marksifspecifically asked.
(Pleasewrite each Degree/Diploma
separately andclearly)
(B)Prescribed Additional Qualification as
peradvertisement
(Degree/ Diploma/ Certificate etc.
Passed showingnameof the college/
Institution/University and year of
passing and p.c. of marks called for in
the
advertisement.
Incomplete/
Incorrect information shall lead to
cancellation ofapplication.)

MasterofComputerApplications(MCA),BangaloreUniversity,
2009,73%

NOTE:ATTACHSUPPORTINGDOCUMENTS

(C) Whetherany experiencerequiredas

per advertisement(details ofname of
institution,location,post, period of
working etc should be shown. Only
experiences relevant tothe
advertisement shouldbementioned)

(Useseparate sheet,ifnecessary)Notapplicable

NOTE:ATTACHSUPPORTINGDOCUMENTS

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(D) ForDoctors, Veterinary Doctors etc.

(i)Registration No.(Wherever necessary) ...Notapplicable
14.ACADEMIC/ PROFESSIONAL QUALIFICATION/TRAININGCOURSES, ETC.fromHSLCOnwards (Useseparate
Sheet,ifnecessary)NOTE: ATTACHSUPPORTINGDOCUMENTS
NameofExam

HSLC

Division
/Grade/
Class

PC(%)of
Marks
Obtained

Yearof
passing

Duration
ofcourse

Institution/Board/University

BaramaHSSchool,

SEBA

SubjectsTaken

73%

2000

NA

NA

HigherSecondary II

54.4%

2003

2Years BaramaCollege,
AHSEC

Science

BscComputer
Science

72%

2006

3Years St.JosephsCollege,
Trichy,
Bharathidasan
University,Trichy

ComputerScience

Masterof
Computer
Applications
(MCA)

73%

2009

3Years CMRInstituteof
managementStudies,
Bangalore,
BangaloreUniversity,
Bangalore

ComputerApplications.

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15.EMPLOYMENT/EXPERIENCE (PARTICULARSOFALL PREVIOUS ANDPRESENT (IFANY EMPLOYMENT)ARETO BE

FURNISHED)

Nameand
Address of
theemployer

Sl.
No.

Postheld

Nature ofWork/Duty

From

2. SAPLabsIndia

Software
Engineer

3. ArcusInfotech

Software
Engineer

SoftwareDevelopment/ 03/2009 02/2011 Private

ApplicationConsultant

16. Detailsoffee

NameoftheTreasury
Office

Consultant

To

Software
02/2013 TillDate Private
Development/
ApplicationConsultant
SoftwareDevelopment/ 02/2011 01/2013 Private
ApplicationConsultant

1.

IBMIndiaPvtltd

Whether
Central/State
Govt.
Undertaking/
Private

Period

ExaminationFee to be paid as per rate if specifically mentioned in the

Advertisement in the HEAD OF THE ACCOUNTS,NON TAX REVENUEOTHERNON
TAX REVENUE 0051 PUBLIC SERVICE COMMISSION102 STATE PUBLIC SERVICE
COMISSIONAPPLICATION/EXAMINATION FEE RECEIPT OF ASSAM PUBLIC SERVICE
COMMISSION.No fee is to be paid if not asked for and the column should be left
blank.

No.andDateof
Treasury
Receipt

Value
Rs.

P.

Reason ofpayment ofhalfrateshould

beclearly stated

NOTE: ENCLOSE COPYOFTHEORIGINAL TREASURY RECEIPT. NODUPLICATE/PHOTOCOPIESWILLBEACCEPTED.

17. OptionalSubjects

: 1.Notapplicable

(IfApplicable)
2.Notapplicable

18. ExaminationCentre

: Guwahati

(IfApplicable)

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19. (a) Are you debarred from any : No

examination and/orselectionconducted
bytheUPSCoranyStateP.S.C.
(b)Areyoudebarred fromapplying for : No
anyGovernment post(Answer YesorNo)
20.DetailsofEnclosures:
1

HSLC Marksheet

HS Marksheet

3 Degree Marksheet

4 HSLC certificate

5 Degree Certificate

6 Photograph

10

11

12

13

14

DECLARATION
Ihereby declare that alltheStatements made inthis application are true and complete tothe
bestofmyKnowledge andbelief. Iunderstand thataction canbetaken against mebytheCommission ifIam
declaredbythemtobeguiltyofanytypeofmisconduct mentioned herein.
* I have informed my Head of Office/Department in writing that I am applying for the post (in
caseofServiceholder).

Place:
Date:Signature oftheCandidate
(Infull)
*Strikeoffthesentence ifnotapplicable.
WARNING: Applications whicharenotin conformity withtherequirements laiddownin the
advertisement and applicationswhich are not in the prescribedform or incompleteor improperly
filled in or are not accompaniedby self attested copies of certificates, mark sheets, documentsetc.
shall be rejected. Applicationreceivedin the Commissionsoffice after the closing date will not be
considered.
Canvassingby a candidate directly or indirectly either to the Chairman or Members
oftheCommission inrespect ofhis/her candidature shallbetreatedasadisqualification.

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