tpz;zg;gg; gbtk;

tpz;zg;gpf;Fk; gjtpapd; ngaH : ________________________________

1 a) tpz;zg;gjhuhpd; ngaH (jkpopy;)

rhd;wpjo;fspy; cs;sgb : gh];NghHl; msT
(b) NameoftheApplicant(inEnglish)as Gifg;glk;
(chpa
perthecertificate(INBLOCKLETTERS) : rhd;nwhg;gj;Jld;)

2 je;ij/fztH ngaH :
3 gpwe;j Njjp :
4 fy;tpj; jFjp (8/10/12Mk; tFg;G :
rhd;wpjo; efy; fz;bg;ghf
,izf;fg;gl Ntz;Lk;. $Ljy; fy;tpj;
jFjpf;F mjw;Fhpa fy;tpr; rhd;wpjo;fspd;
efy; ,izf;fg;gl NtzL;k);
5 ,dg;gphpT (chpatw;iwj; NjHe;njLf;fTk;) :
6 [hjp (cl;gphpTld;) :
7 Njrpa ,dk;/kjk; Nationality/Religion :
8 gpwg;gplk; :
9 jpUkzkhdtuh? :
10 epue;ju Kfthp :
11 Kd; mDgtk; :
12 Kd;Dhpik NfhUfpwPuh ? (Mk; vdpy;>
chpatw;iw NjHe;njLf;fTk;> chpa
rhd;wpjopd; efy; ,izf;fg;gl Ntz;Lk;)
:
(i)Mjutw;w tpjit
(ii)khw;Wj; jpwdhsp
(iii)Kd;dhs; ,uhZt gil tPuH/rhHe;NjhH
(iv)fyg;Gj; jpUkzk; nra;J nfhz;ltH
(v)01.06.1981 Njjpf;F Kd;
muRg;gzpapypUe;J tpLtpf;fg;gl;l muR
gzpahsHfs;
(vi) muR gzpfSf;fhf epyk;
ifafg;gLj;jg;gl;l egHfs;
(vii) jhafk; jpUk;gpNahH(gHkh/=yq;fh
kw;Wk; fpof;F Mg;gphpf;fh ehLfs;)s
(viii) jha; kw;Wk; je;ijia ,oe;j kfd;/
kfs;
(ix) kf;fs; njhif fzf;nfLg;G
mikg;gpypUe;J ePf;fg;gl;l CopaHfs;
(Fiwe;jgl;rk; 6 khjj;jpw;F Nky;
gzpGhpe;jpUf;f Ntz;Lk;)
(x) vy;iyNahu ghJfhg;G
gzpapypUe;jtHfs; (Fiwe;jgl;rk; 6
khjj;jpw;F Nky; gzpGhpe;jpUf;f Ntz;Lk;)
(ix) ,isQH fhty;gil (Fiwe;jgl;rk; xU
tUl fhyk; gzpGhpe;jpUf;f Ntz;Lk;)
13 jkpo; topf;fw;wtuh?(Mk; vdpy;> chpa :
rhd;wpjopd; efy; ,izf;fg;gl Ntz;Lk;)
14 Ntiy tha;g;G mYtyfj;jpy; gjpT :
nra;Js;shuh? Mk; vdpy;> vz;izf;
Fwpg;gpLf. chpa Mtzj;jpd; efy;
,izf;fg;gl Ntz;Lk;)
15 tpz;zg;gjhuhpd; Nky; fhty;Jiwapy; :
tof;F vJTk; epYitapy; cs;sjh ?
16 ,izf;fg;gl;l rhd;wpjo;fspd; efy;fs; :
tptuk;

,lk; :
ehs; : tpz;zg;gjhuhpd; ifnahg;gk;
 APPLICATION FORM

Applying for the Post of -------------------------------------

1 (a) Name of the Applicant ( in Tamil ) as : Passport size

per the Certificate photograph
(b) Name of the Applicant (in English) with attested
as per the Certificate
( IN BLOCK LETTERS )
2 Father / Husbands Name :
3 Date of Birth :
4 Educational Qualification (Xerox copies :
of 8/10 /12 Std Mark Sheet should be
attached. For Additional Qualification
certificate Copies should also be
attached)
5 Class ( Choose Prior ) : OC/BC/MBC/SC/ST
6 Caste ( mention Sub Caste) :
7 Nationality / Religion :
8 Place of Birth :
9 Marital Status :
10 Permanent Address :
11 Experience (if any) :
12 Preference ( if Yes, Choose and attach
the copies of the certificate) :
(i)Destitute Widow
(ii)Physically Handicapped
(iii)Ex Serviceman / Dependant
(iv)Inter Caste Marriage
(v)Discharged Government Employees
prior to 01.06.1981.
(vi)Person whose Land have been
acquired for Government.
(vii)Repatriation (Burma / Sri Lanka and
East African Countries)
(viii)Heirs (Son / Daughter ) who have
lost both Father and Mother.
(ix)Retrenched employees of the
Census, Organization without less than 6
months service.
(x)Persons who served in the Territorial
Army for More than 6 months.
(xi)Persons who worked as Youth
Services Corps Volunteers for a
minimum period of one year.
13 Whether studied in Tamil Medium :
(If yes, attach)
14 Whether Registered in Employment :
Exchange? If yes, mention the registered
number and attach the Document copy
of the Certificate.
15 Whether any Case is pending in the :
Police Department
16 Particulars of Attached Documents :

Place: Signature of the Applicant

Date: