Applicant's Name : *
                  First Name

Middle Name

Last Name

Birth Date : *

/ /

Residential Address (Present) : *
   Pin code :    Ward :

Residential Address (Permanent) : *

Mobile No :

Religion :

Caste :

Sub-Caste :


Occupational group :

Serial no of the caste in the state list of OBC :

Father's Name :
                  First Name

Middle Name

Last Name

Mother's Name :
                  First Name

Middle Name

Last Name

Parent's/husband's details :
     (a) Constitutional post :

     (b) Designation :

(A) Government Services/Other services :

     (i) Service (Central/State/Other) :

     (ii) Designation :

     (iii) Scale of pay including :
           Classification if any

     (iv) Date of appointment to post :

     (v) Age at the time of promotion :
          To class/post (if Applicable)

   II Employment in International :
      Organisation e.g. UNICEF

      (a) Name of the Organisation :

      (b) Designation :

      (c) Period of service indicate date from :

(B) Death Permanent incapacitation  :
      (omit if not applicable)

     (a) Date of Death / Permanent :
           Incapacitation Putting an Officer of service.

     (b) Details of permanent incapacitation :
           To class/post (if Applicable)

(C) Employment in public sector  :
      Undertaking Put organization/ Profession

     (a) Name of the Organisation :

     (b) Designation :

     (c) Date of appointment of the post :

(D) Armed forces including para-Military  :
      forces.(The Will not Include persons holding the Post)

(E) Professional Class (other than those) :

(F) Property :

(F) Agriculture Land holding owned :
Mother, Father and minor Children

(a) Location :

(b) Size of holding :

(c) (a) Irrigated

(i) :

(ii) :

(iii) :

            (b) Non- Irrigated
                 (To be certified by District Statutory
                  Revenue Officer not Lower than)

                    (iv) Percentage of irrigated land holding to :
                          selling limit under state of Land Selling

                    (v) If land holding is not irrigated unirrigated  :
                         total irrigated land holding on the basic of
                         conversion formula in State Land Selling

                   (vi) Percentage of total Irrigated land holding :
                         to Statutory Selling Hands as per (IV)

(H) II Plantation :
      (i) Crops / Fruits :

      (ii) Location :

      (iii) Area of plantation :

(I) Vacant land and/or building and urban areas :
      (i) Location of property :

      (ii) Detail of property :

      (iii) use to without input :

(J) Income / wealth :
      (i) Annual frankly income excluding salary
          and income from agricultural land :

      (ii) Whether tax payer :

      (iii) Whether converted in wealth tax :

(K) Any other remark :

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