SJVN Limited
(A joint venture of Govt. of India & Govt . of H.P)
An ISO 9001:2000 Company & A Mini Ratna & Schedule ‘A’ PSU
APPLICATION FORMAT
Affix recent
(Use Block Letters Only)
Advt. No. 77/2015
passport size
(Please fill up this form with utmost care)
Incomplete Application form is liable to be rejected.
Photograph
Post applied for: _________________________Level __________
(e.g Assistant Trainee)
here
(W3)
A. PERSONAL DETAILS: 1. Name (as appears in SSC certificate)
Please put a space between your first name, middle name (if any) and last name.
2. Father’s Name
3. Date of Birth
DD
MM
Yr
4. Age as on closing date
YYYY
Month
Days
Sex: (Write M or F)
5. State of Domicile:
6. Whether Domicile in the Sate of J&K during 01.01.1980 – 31.12.1989 (Yes/No)
B. CORRESPONDENCE ADDRESS:
City/Town:
State
Telephone Number
STD Code
Pin Code:
Telephone Number
C. PERMANENT ADDRESS:
City/Town:
State
Telephone Number
STD Code
Pin Code:
Telephone Number
Mobile No.
D. ACADEMIC PERFORMANCE :
1. Basic Qualifications –
Exam
Passed
Institution/
University/
Board
Subjects studied/ Branch of
Specialization
Duration of
study
Month & Year
of passing
(MM/YYYY)
Aggregate%
of marks *
Full Time /
Part Time/
Correspondence
2.
Professional Qualifications (Please mention qualification which makes you eligible)
Exam
Passed
Institution/
University/
Board
Subjects studied/ Branch of
Specialization
Duration of
study
Month & Year
of passing
(MM/YYYY)
Aggregate%
of marks *
Full Time /
Part Time/
Correspondence
Duration of
study
Month & Year
of passing
(MM/YYYY)
Aggregate%
of marks *
Full Time /
Part Time/
Correspondence
Additional Qualification (if any)
Exam
Passed
Institution/
University/
Board
Subjects studied/ Branch of
Specialization
(*If it is Cumulative Grade Point Average (CGPA), please convert it to % of Marks)
E. Category:
(
GEN/SC/ST/OBC/Ex-ser
F. Are you physically handicapped (Yes/No?)
If yes please mention the details as follows:
Type of handicap:
Extent of disability as specified in the disability certificate:
G.
DETAILS OF EXPERIENCE (If required, please attach separate sheet)
Name of
Organization
Designation
Scale of
Pay
Duration
From
(MM, YYYY)
Post Qualification Total experience: Years
H.
DETAILS OF DEMAND DRAFT
Demand Draft No.
Date
Regular/Contract/dai
ly wage
Nature of
duties
Reason for
Leaving
To
(MM, YYYY)
Months
(Bank Drafts should be payable at Shimla only)
Name of Bank
Amount
I
Are you working in SJVN?
Yes/No
If yes :a) On Regular basis ________________OR Under Contract______________________________
b) Name & Address of the Contractor / Employer___________________________________________
________________________________________________________________________________
J. Have you ever been convicted by any court of law or any disciplinary proceedings/enquiry is pending
against you or any penalty has been imposed upon you? If yes, give details.
Declaration:
I affirm that the information given in this application is true and correct to the best of my knowledge and
belief. I further undertake that if at any stage it is discovered that an attempt has been made by me, will fully
to conceal or misrepresent the facts, my candidature/appointment shall be summarily rejected or terminated
without any notice.
Date: _______________________
Signature:________________________
Place: ______________________
Name: ___________________________
Please Enclose:
1.
Attested proof of SC/ST/OBC/PWD/ Ex-Servicemen/ State Domicile Certificate. In case of OBC,
Non- Creamy Layer Certificate.
2.
The candidates should also enclose attested certificates in support of age, educational qualifications,
experience etc. along with their applications.
A
FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING
FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF NDIA
[G.I. Dept. of Per. & Trg., O.M. No. 36033/28/94-Estt.(Res.), dated 2-7-1997]
This is to certify that ……………………………………., S/o. …………………………, of village
………………….. District/Division ……………………………. in the ……………… State
………………….. belongs to the …………………….. community which is recognized as a Backward
Class under –
*(i)
Government of India, Ministry of Welfare, Resolution No. 12011/68/93-BCC (C),
dated the
10th September, 1993, published in the Gazette of India, Extraordinary, PartI, Section I, No. 186,
dated the 13th September, 1993.
*(ii) Government of India, Ministry of Welfare, Resolution No. 12011/9/94-BCC, dated the 19th
October, 1994, published in the Gazette of India, Extraordinary, Part-I, Section I, No. 163, dated the 20th
October, 1994.
*(iii) Government of India, Ministry of Welfare, Resolution No. 12011/7/95-BCC, dated the 24th May,
1995, published in the Gazette of India, Extraordinary, Part-I, Section I, No.
88, dated the 25th May,
1995.
*(iv) Government of India, Ministry of Welfare, Resolution No. 12011/44/96-BCC, dated
the
6th
December, 1996, published in the Gazette of India, Extraordinary, Part-I, Section
I, No. 210, dated
th
the 11 December, 1996.
Shri
…………………………………..
and/or
his
family
ordinary
reside(s)
in
the
…………………………………………………. District/Division of the ………………... State. This is also
to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned in the Column 3 of
the Schedule to the Government of India, Department of personnel and Training O.M. No. 36012/22/93Estt. (SCT), dated 8-9-1993.
Dated:
District Magistrate
Deputy Commissioner
SEAL
*Strike out whichever is not applicable.
N.B.- (a)
The term of ‘Ordinary’ used here will have the same meaning as in Section 20 of the
Representation of the People’s Act, 1950.
(b) The authorities competent to issue caste certificates are indicated below:(i)
District Magistrate / Additional Magistrate / Collector/ Deputy Commissioner / Additional
Deputy Commissioner / Deputy Collector / First Class Stipendiary Magistrate / Sub-Divisional
Magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant Commissioner (not
below the rank of First Class Stipendiary Magistrate).
(ii)
Chief Presidency Magistrate / Additional Chief presidency Magistrate / Presidency Magistrate.
(iii)
Revenue Officer not below the rank of Tehsildar; and
(iv)
Sub-Divisional Officer of the area where the candidate and/or his family resides.
Self Undertaking for OBC Candidates
I,_______________________________________________________
_________________________________________________________
son/daughter
resident
of
of
Shri
village/town/city
________________________________________________________
district
____________________________________ state _______________________ hereby declare that I belong
to the __________________________________________ community which is recognized as a backward
class by the Government of India for the purpose of reservation in services as per orders contained in
Department of Personnel and Training Office Memorandum No. 36012/22/93-Estt.(SCT) dated 8-9-1993. It
is also declared that I do not belong to persons/sections (Creamy Layer) mentioned in Column 3 of the
Schedule to the above referred Office Memorandum dated 8-9-1993.
Date:
Signature
Form of Certificate to be produced by a candidate belonging to a Scheduled Caste or
Scheduled Tribe in support of his claim
-------------------------------------------------------------------------------------------------------FORM OF CASTE CERTIFICATE
This is to certify that Shri / Shrimathi* / Kumari* …………………………………….…………….. Son /
Daughter* of …………………………………………….. of Village / town* …………………………… in
District /
Division*…………………….. of the State / Union Territory*……………………………………….
belongs to the …………………………….……….. Caste/ Tribe* which is recognised as a Scheduled
Caste / Scheduled Tribe*.
Under
The Constitution (Scheduled Caste) Order, 1950
* The Constitution (Scheduled Tribe) Order, 1950
* The Constitution (Scheduled Caste) (Union Territories) Order, 1951
* The Constitution (Scheduled Tribe) (Union Territories) Order, 1951
(as amended by the Scheduled Caste and Scheduled Tribes Lists (Modification Order), 1956, the
Bombay Reorganisation Act, 1960, the Punjab Reorganisation Act, 1966, the State of Himachal
Pradesh Act, 1970, the North Eastern Areas (Reorganisation) Act, 1971 and the Scheduled Castes
and Scheduled Tribes Orders (Amendment) Act, 1976).
* The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956
* The Constitution (Andaman & Nicobar Islands) Scheduled Tribes Order, 1959 as amended by
the Scheduled Castes and Scheduled Tribes Orders (Amendment) Act, 1976.
* The Constitution (Dadra & Nagar Haveli) Scheduled Castes Order, 1962
* The Constitution (Dadra & Nagar Haveli) Scheduled Tribes Order, 1962
* The Constitution (Pondicherry) Scheduled Castes Order, 1964
* The Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967
* The Constitution (Goa, Daman & Diu) Scheduled Castes Order, 1968
* The Constitution (Goa, Daman & Diu) Scheduled Tribes Order, 1968
* The Constitution (Nagaland) Scheduled Tribes Order, 1970
* The Constitution (Sikkim) Scheduled Castes Order, 1978
* The Constitution (Sikkim) Scheduled Tribes Order, 1978
* The Constitution (Jammu & Kashmir) Scheduled Tribes Order, 1989
* The Constitution (Scheduled Castes) Orders (Amendment) Act, 1990
* The Constitution (Scheduled Tribes) Orders (Amendment) Act, 1991
* The Constitution (Scheduled Tribes) Orders ( Second Amendment) Act, 1991
2. ** This Certificate is issued on the basis of the Scheduled Caste / Scheduled Tribe Certificate
issued to Shri / Shrimathi*……………………………………………….father / mother* of Shri / Shrimathi/
Kumari*………………………………..of Village / Town* ………………….District/ Division* of the
State / Union Territory*………………………………………………….. who belong to the Caste/ Tribe*
which is recognised as a Scheduled Caste / Scheduled Tribe* in the State / Union Territory
…………………………………………… issued by the …………………………………………dated
……………………….
: 02 :
3. Shri / Shrimathi / Kumari* ………………………………………………… and / or* his / her* family
ordinarily reside(s) in the village / town* ………………………………… of ………………………….
District / Division* of the State / Union Territory* of ……………………………………..
Signature ……………………………………….
Designation……………………………………..
(With Seal of Office)
Place……… ……………………….
Date…………………………………
State
Union Territory
* Please delete the words which are not applicable
** Applicable in the case of SCs/STs persons who have migrated from one State / UT.
NOTE: The term `Ordinarily’ reside(s) used here will have the same meaning as in Section 20 of
the Representation of the Peoples Act, 1950.
---------------------------------------------------------------------------------------------------------------------------AUTHORITIES EMPOWERED TO ISSUE CASTE CERTIFICATES
The under mentioned authorities have been empowered to issue Caste Certificates of
verification---1.
2.
3.
4.
5.
6.
District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner/
Additional Deputy Commissioner/ Deputy Collector / I class Stipendary Magistrate / Sub –
Divisional Magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant
Commissioner.
Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.
Revenue Officer not below the rank of Tehsildar.
Sub – Divisional Officer of the area where the candidate and / or his family normally resides.
Revenue Divisional Officers – in the case of candidates belonging to Scheduled Tribes of
Tamilnadu.
Administrator / Secretary to the Aadministrator / Development Officer ( Lakshadeep Islands)
NAME AND ADDRESS OF THE INSTITUTE / HOSPITAL
CERTIFICATE NO. … … …
DATE: … … … …
DISABILITY CERTIFICATE
Recent Photograph of the
candidate showing the
Disability duly attested by
the ChairPerson of the
Medical Board
This is certified that Shri/Smt/Kumari …………………………………………………............................
Son/Wife/Daughter of Shri ……………………………......… age ……………....…. Sex ………….… identification
mark(s) ……………………………... is suffering from permanent disability of following category:
A.
Locomotor or Cerebral Palsy:
(i)
BL – Both Legs affected but not arms.
(ii)
BA – Both Arms affected:
(a) Impaired reach.
(b) Weakness of grip.
(iii)
BLA – Both Legs and Both Arms affected.
(iv)
OL – One Leg affected (Right or Left) (a) Impaired reach.
(b) Weakness of grip.
(c) Ataxic
(v)
OA – One Arm affected.
(a)
Impaired reach.
(b) Weakness of grip.
(c) Ataxic
(vi)
BH – Stiff back and hips (Cannot sit or stoop)
(vii)
MW – Muscular weakness and limited physical endurance
B.
Blindness or Low Vision:
i. B – Blind
ii. PB – Partially Blind
C.
Hearing impairment:
i. D – Deaf
ii. PD – Partially deaf.
(Delete the category whichever is not applicable)
2
This condition is progressive/non-progressive/likely to improve/ not likely to improve. Re-assessment of this
case is not recommended/is recommended after a period of ……......… years…….....… months*.
3
Percentage of Disability in his/her case is ……....…….. Percent.
4
Shri/Smt./Kumari…………………………………………………............................ meets the following
physical requirements for discharge of his/her duties: (i)
F – can perform work by manipulating with fingers
… … Yes/No
(ii)
PP – can perform work by pulling and pushing
… … Yes/No
(iii)
L – can perform work by lifting
… … Yes/No
(iv)
KC – can perform work by kneeling and crouching
… … Yes/No
(v)
B – can perform work by bending
… … Yes/No
(vi)
S – can perform work by sitting
… … Yes/No
(vii)
ST – can perform work by standing
… … Yes/No
(viii) W – can perform work by walking
… … Yes/No
(ix)
SE – can perform work by seeing
… … Yes/No
(x)
H – can perform work by hearing/speaking
… … Yes/No
(xi)
RW – can perform work by reading and writing
… … Yes/No
(Dr……………………)
Member
Medical Board
(Dr……………………)
Member
Medical Board
(Dr……………………)
Chairperson
Medical Board
Countersigned by the Medical Superintendent/
CMO/Head of Hospital (with seal)
* Strike out which is not applicable.