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Recruitment of Officer MMG Scale III, Officer MMG Scale II, Officer JMG Scale -I and Office Assistant (Multipurpose)

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Please paste your recent passport size photograph and sign across it. Please retain atleast 5 copies of same photograph with you for subsequent use.

Registration #: Full Name : Post : Post Code : Category : If physically challenged : Type of Disability : Percentage of Disability : Do you intend to use the services of a scribe (only for VI & OC candidates whose writing speed is affected by cerebral palsy) : Whether you belong to Religious Minority Community? : Religion to which you belong : Whether domiciled in Kashmir Division of the State of J&K during the period 1-1-1980 to 31-12-1989 ? : Are you an Ex-Serviceman? : Date of Discharge : Are you a disabled Ex-Serviceman (DISXS)? : Period of service rendered in defence services as an Ex Serviceman (in months) : Are you Dependent Ex-Serviceman (DXS)? :

1038721 PUJA SINGH Office Assistant (Multipurpose) 04 GENERAL NO NA NO -NO NO NO -NO

Are you seeking relaxation under widow / divorced women / women judicially Separated NO from their husbands and who are not re-married? : Nationality : Centre of Examination : Centre code : Application Fee / Postal Charges Details : Payment In : Transaction ID : Branch Name : Branch Code No : Deposit Date : Amount : Punjab National Bank M121252 PNB ANISHABAD PATNA 6059 10-03-2012 450 INDIAN Patna 11

Personal Details : Date of Birth : Age completed as on 01.04.2011: Gender : Marital Status : Father's Name / Husband's Name : Mother's name : Contact Details: Address for Correspondence : SINGH MORE VIKASH NAGAR LATMA ROAD NO 8/B NEAR MISSION HOSPITAL HATIA 04-09-1991 19 FEMALE Unmarried TARA PRASAD SINGH LILA DEVI

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District : State : Pin code : Permanent Address : RANCHI JHARKHAND 834003 SINGH MORE VIKASH NAGAR LATMA ROAD NO 8/B NEAR MISSION HOSPITAL HATIA District : State : Pin code : Contact Details : Phone Number : Mobile Number : Email ID : Qualification Details (as on 01.04.2011): Exam Passed Graduation / Equivalent : Working Knowledge of Computers : Details of Computer Knowledge : Post Qualification work experience details (Start from present Employer): Name of the Employer & Nature of Employment Designation and Rank From(mm/yyyy) To(mm/yyyy) Nature of duties performed Reason for Leaving Year of Service (YY/MM) Name of the Subject/Stream Science Year of Passing 2011 YES MS WORD % of Marks 65.00 Class/Grade First Class 9835130131 sanjeevsingh.ece@gmail.com RANCHI JHARKHAND 834003

Total Experience (in months) : Other Details : Whether desirous of taking Pre-Exam Training (Only for -SC/ST/Minority/EXS ) : If Yes Centre for Training : -Languages Known Hindi ENGLISH Read YES YES

Write YES YES

Speak YES YES

DECLARATION:
I hereby certify that the above information furnished is correct to the best of my knowledge and belief. I have not suppressed any material fact or factual information in the above statement. I am aware that in case I have given wrong information or suppressed any material fact or factual information or I do not satisfy the eligibility criteria according to the advertisement, then my candidature will be rejected/ service terminated even after permanent employment without giving any notice or reasons thereof. I hereby certify that I am satisfying the eligibility criteria for the post applied for in terms of advised criteria in respect of age, caste, educational qualification etc. I hereby agree that any legal proceeding in respect of any matter or claims or disputes arising out of application or out of said advertisement can be instituted by me only at Muzaffarpur and courts/ Tribunal/ forums at Muzaffarpur only, shall have sole and exclusive jurisdiction to any cause/ dispute. I undertake to abide by all the terms and conditions in the advertisement given by the Bank.

Place: Date: 13-03-2012 Signature of Applicant

PUJA SINGH

Please retain your Registration No. and Password emailed to you carefully for further reference NOTE: Please DO NOT SEND application print-out to the Bank