ONLY ONLINE APPLICATION WILL BE ACCEPTED FORM IS INDICATIVE ANNEXURE-I

FOOD CORPORATION OF INDIA Combined Recruitment for Assistant Grade III in General, Depot, Technical and Account Cadres

in FCI, 2013

... ,, , 2013 BE{ {F BE x] nA MA +xn / BE Bvx {BBE {f * Please read instructions in the Notice of the Examination/Annexures carefully.

1. {F BExp BE x / Name of the Examination Centre 2. {F BExp BEb / Examination Centre Code 3. =nB BE { x (+OV ) ]BEx |h {j nA MA x BE +x +F J * x BE n M BE S ABE BD BE J U n * Candidates Full Name (in English). Write in Capital Letters exactly as in Matriculation Certificate. Leave one box blank between every two parts of the name. 4. {i BE x (+OV BE +F J) / Fathers Name (Write in Capital Letters in English)

5. i BE x (+OV BE +F J) / Mothers Name (Write in Capital Letters in English) 6. Vx BE iJ / Date of Birth nx / Day cx /Month /Year

7. M / Gender (J 1-j AB 2-{) (Write 1-Female & 2- Male)

8. /Nationality (J 1-i AB 2-+x) (Write 1-Indian & 2 - Others)

9. BE / Fee (J 1-BE BE Mix n 2- U] BE nB BE) (Write 1-Fee paid & 2- Exemption claimed)

10. gh / Category (J 9-+x,1 +V,2 +VV AB 6-+{B) (Write 9-General, 1-SC, 2-ST, 6-OBC)

10.1 +{ i{B xBE c ? If Ex-serviceman 3 J Write 3 in the box

10.2. i{B xBE BE A For Ex-Serviceman B +Bv / Length of Service [ /Year]

B {i il/Date of Discharge (nx/Day cx/Month /year)

11. BD +{ BE BBEM c ? Whether PWD ?

(J 1-c AB 2-xc) (Wrire 1-Yes, 2-No)

11.1 n c, BEb +BEi BE If yes, indicate code (J 4-+.B., 5-g.B.) (Write 4-OH, 5-HH, 7-VH )

11.2 If VH, whether scribe is required (Write 1-yes, 2-No) , ( 1-,, 2-)

11.3 If scribe required medium in which examination will be taken (Write 1 - English, 2 Hindi) , ( 1, 2 )

12. BD + U] Sci? Whether seeking Age relaxation? (J 1-c AB 2-xc) (Write -1-Yes, 2-No)

12.1 n c, BEb +BEi BE If yes, indicate code (n +BE BE JiBE BEb +BEi BE) (Write two digit numeric code)

12.2 01.08.2012 BE + / Age as on 01.08.2012 / Years cx / Months nx / Days

13. BD +{ +{JBE c? (J 1-c AB 2-xc) Whether belong to Minority Communities ? (Write 1-Yes, 2-No)

14. BE |lBEi Preference for Zones

1 2 3 4 5 Write A for East, B for West, C for North, D for South and E for North East zones.

14.1 Preference for posts 1 2 3 4 See Note IV of para A3 of the Notice

14.2 Are you applying for the post of AG III (Accounts). Write 1-Yes, 2-No -() 1-, 2- Do you possess qualification for AG III (Accounts). Write 1-yes, 2-No. -() 1-, 2-

14.3 Are you applying for the post of AG III Technical. Write 1 yes, 2 No. -() 1-, 2- Do you possess qualification for AG III (Technical). Write 1 yes, 2 No. -() 1-, 2-

15. FBE Mi Educational Qualification BEb +BEi BE Indicate Code [See Annex III]

16 Subject Code (See AnnexIV)

17 +BE BE |ii (%) Percentage (%) of Marks

18 v (+OV-1, cxn-2 B +x-3) Medium ( English-1, Hindi-2, Others-3)

19. Details of work Experience / Govt. Service BE +xB BE BBh Name of the Organisation(s) l BE x

Designation {nx Name of the Duty(ies) BE BE BBh

Period of Service BE BE +Sv From To

20. {i: +{x x ci {j BBc BE { {i +OV BE +F cxn x BE {x J * Address: Write your complete Communication Address including your Name in English Capital Letters or Hindi with Blue or Black Ball Pen.

22.=nB BE ciF (BEB P] ci{ )

Signature of the Candidate in the left Box (Only in running Hand)

(Page 1 of 2)

Name___________________________________________________

Address_________________________________________________ ___________________________________________________________ ___________________________________________________________ PIN:

./ Mobile No. : .........................................................

/Email ID:.....

21. {E]O{E 4 x 5 +BE BE

c c JS M {E]O{E c ~BE fM S{BE * (]{ x BE * {E] BE

i{i x BEBA) Photograph

Paste here firmly your recent photograph

(4 c.m.X 5c.m) (Do not staple. Do not get the

Photograph attested)

+xEBE (BEB BE |M ci)

Roll Number (for Office use only)

http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22

23. /Declaration

(i ) /

I have not submitted any other application for this examination. I am aware that if I contravene this rule, my application will be rejected summarily by the FCI.

(ii) , / I have read the provisions in the Notice of the examination carefully and hereby undertake to

abide by them. (iii) / , ,

/ I further declare that I fulfill all the conditions of eligibility regarding age limits, educational

qualifications etc., prescribed for admission to the examination. (iv) / FCI

/

I also declare that I do not stand debarred by FCI as on date and have never been convicted by any court of law. I also declare that no charge sheet is pending against me in any court of law. Further declare that I have never been dismissed or removed from Govt. Service or PSU Service or my service been terminated during probation.

(v) For FCI Employees seeking age relaxation. I declare that I am a FCI Employee. (vi) * / 8.9.1993

36012/22/93- ( ) , . 3 / ( ) / / /

*For Candidate belonging to OBC. I declare that I belong to the community which is recognized as a backward class by the Govt.

of India for the purpose of reservation in services as per order contained in Deptt. of Personnel and Training Office Memorandum No.36012/22/93-Estt.(SCT) dated 8.9.1993. I also declare that I do not belong to the person/sections (creamy layer) mentioned in column 3 of the schedule of the OM mentioned above and modified vide Govt. of India DOPT OMs mentioned in the Notice. I further declare that I am in possession of OBC Certificate in the prescribed format given in the Notice of the examination or will submit valid OBC Certificate at the time of Skill Test/Typing Test as per the provision of the Notice.

(vii) / / For Candidate belonging Ex-Serviceman I declare that I fulfill all the eligibility conditions relating to Ex-Serviceman as per notice of

examination and Government of India guidelines. (viii) /

, / / / I hereby declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found suppressed/false or incorrect or ineligibility being detected before or after the examination, my candidature/appointment is liable to be cancelled.

lx/Place: .. D D M M Y Y

iJ/Date:

* n M x c i c