Regn No.

_____________
APPLICATION FORM (For official use only)

APPLICATION FOR THE POST OF LDC/MTS (PEON) Passport size

To, photograph
OIC Records duly attested
Records 58 GR
by a Gazette
Happy Valley, Shillong-7
Officer
1. Name in full (Capital)
Surname Name Father/Husband Name

2. Date of Birth (Proof attached)

Date Month Year

3. Age as on 15 Feb 2017 _____________ Years________________ Months

4. Permanent Address _________________________________________________________
_________________________________________________________

5. Local Address _________________________________________________________

_________________________________________________________
6. Caste (CTC of cert issued by competent auth to be att) _____________________________________
7. Education Qualification (Xerox copy duly attested)

Exam Passed School/Board/ Subject Total Marks Percentag Division

University Obtained e of marks
(a) (b) (c) (d) (e) (f)

8. Experience, if any ______________________________________________________________

(Xerox copy duly attested attached)
9. Have you been convicted in criminal case : Yes/No
10. Contact No (Telephone/Mobile No.) __________________________________________________
11. Email ID ________________________________________________________________________

DECLARATION

I, hereby declare that all statements made in the application are true and correct to the best of my
knowledge and belief.

I, understand that in the event of particulars or information given hereby being found false or incorrect
my candidature for the examination is liable to be rejected or cancelled and on the event of my mis-
statement/discrepancy in the particulars being detected after my appointment my services are liable to be
terminated without notice to me.

Date : (Signature of Candidate)

Davp 10622/11/0062/1617