Application Form Revised - 5

APPLICATION FORM
Photograph should be
self-attested.
1. Vacancy Notice No.

&
Name of the Post applied for
2. Applying for Regular/Absorption/Deputation/Contract/Re-employment

(Tick whichever is applicable)
3. Name of the Present Organisation
4. Present Designation:
5. Candidate’s Name (in capital letters) (Please keep one box blank between name,
middle name & surname)
6. Father’s/Husband’s name (in capital letters) (Please keep one box blank between
name, middle name & surname)
7. Date of Birth Day Month Year
Age as on cut-off date Years Months Days
8. Date of Retirement Day Month Year
1
9. Details of Educational Qualification possessed by the officer:
Percentage of
Board/ Year of
Qualification Specialization Institute marks (Max. 2
University Passing
decimal)
10th / SSC
ITI/Inter/+2
Details of Essential Qualification for the post applied
Percentage of
Board/ Year of
University Passing
decimal)
Diploma
B.E/B. Tech
Details of Additional Qualification
Percentage of
Board/ Year of
University Passing
decimal)
9. b) Details of Qualification in Japanese Language Proficiency Test (JLPT):
Level of Proficiency Month & Year of Passing Score/Marks Obtained
2
10. Details of employment# in chronological order. Enclose a separate sheet duly
authenticated by your signature, if the space below is insufficient.
Period of Clearly indicate the

Name and Scale Service Total nature of experience.
address of Designation of Pay Experience Also mention the
employer From To in years name of the project/
unit where worked
# The employment should be supported by way of documentary evidence i.e work

certificate from employer, appointment letter from organisations, pay slips etc.
10. a) Details of Experience as Trainer/Faculty.
Sl. No. Name of the Institute Subjects Handled Period
11. APAR/ACR gradings for last 3 years (Please attach copies):
2018-19 2017-18 2016-17
3
12. Nature of present employment i.e., Ad-hoc/Temporary/Contractual/Regular (Tick
whichever is applicable)
13. Additional details about present employment:
a) Central PSU/Joint Sector/SPV

b) Metro Railway
(c) Pvt Sector
(d) Any other sector
14. Details of pay particulars (Copy of last Salary Slip duly self-attested to be
attached):
a) Are you in CDA or IDA pay:

b) If in CDA, please indicate the Pay, Pay Band and Level:
c) The Pay, Pay band and level held under MACP, if applicable:
d) If in IDA, please indicate the pay scale:
e) Whether in pre revised or revised scale of Pay (CDA/IDA):
f) If in Pre-revised scale of pay in IDA then indicate the pre-revised scale and the
corresponding revised scale of pay in IDA:
115. Total emolument per month

(Give break up & attach a copy of latest
pay slip)
16. Additional information, if any, which you would like to mention in support of your
suitability for the post. Amongst other things may provide information with regard
to (i) Additional academic qualifications (ii) Professional training and (iii) Work
experience with respect to job description of the post advertised) (The details should
not be in more than 200 words. Enclose a separate sheet, if the space is insufficient)
4
17. Community SC ST OBC GEN
18. Present Address (in capital letters)
(a) Name of the nearest Railway Station: __________________________
19. Permanent Address (in capital Letters)
20. Mobile No 1) 2)
21. Email id
22. References (Of 2 Senior Officers with whom you have worked for a minimum of 2
years or more)
5
I II
Name
Designation
Organisation
Mob
email
6
DECLARATION TO BE SIGNED BY THE CANDIDATE
I hereby certify and declare that (i) I have carefully gone through the vacancy
circular/advertisement and I am well aware that the Curriculum Vitae duly supported by
documents submitted by me will also be assessed by the selection Committee at the time
of selection for the post, (ii) All statements made and information given by me in this
application are true, complete and correct to the best of my knowledge and belief. In the
event of any information or part of it being found false or incorrect before or after the
interview or appointment, criminal action can be initiated against me by NHSRCL and my
candidature/appointment shall automatically stand terminated, (iii) I further declare that I
fulfil all the conditions of eligibility prescribed for the post applied for. (iv) In case my
application is not received by NHSRCL within the stipulated date due to postal delay or
otherwise, NHSRCL will not be responsible for such delay.
23. List of Enclosures: (i) (ii)

(iii) (iv)
(v) (vi)
Place:
Date: (Signature of the Applicant)
24. Declaration about DA/VIG/SPE/CBI/CRIMINAL CASEs
For Candidates applying on absorption basis/Deputation Basis*
I hereby certify that I do not have any Disciplinary case/Vigilance Case/Any case arising
out of SPE/CBI pending against me. I do not have any Criminal Proceedings pending
against me.
I further certify that I am not undergoing any punishment as on the date of this application.
(Signature of the Applicant)
*Candidates applying on deputation have to provide an additional DA/Vig/SPE clearance

certificate from their employers
Countersigned
…………………
………………….
(Employer with Seal)
In cases of deputation

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Application Form Revised - 5

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APPLICATION FORM

1. Vacancy Notice No.

2. Applying for Regular/Absorption/Deputation/Contract/Re-employment

3. Name of the Present Organisation

7. Date of Birth Day Month Year

Age as on cut-off date Years Months Days

8. Date of Retirement Day Month Year

Details of Essential Qualification for the post applied

Details of Additional Qualification

9. b) Details of Qualification in Japanese Language Proficiency Test (JLPT):

Level of Proficiency Month & Year of Passing Score/Marks Obtained

Period of Clearly indicate the

# The employment should be supported by way of documentary evidence i.e work

10. a) Details of Experience as Trainer/Faculty.

Sl. No. Name of the Institute Subjects Handled Period

11. APAR/ACR gradings for last 3 years (Please attach copies):

2018-19 2017-18 2016-17

13. Additional details about present employment:

a) Central PSU/Joint Sector/SPV

a) Are you in CDA or IDA pay:

115. Total emolument per month

18. Present Address (in capital letters)

(a) Name of the nearest Railway Station: __________________________

19. Permanent Address (in capital Letters)

23. List of Enclosures: (i) (ii)

Date: (Signature of the Applicant)

24. Declaration about DA/VIG/SPE/CBI/CRIMINAL CASEs

For Candidates applying on absorption basis/Deputation Basis*

(Signature of the Applicant)

*Candidates applying on deputation have to provide an additional DA/Vig/SPE clearance

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