No. of advertisement __________ & date ________________________ Post applied for - ______________________________	e-Transfer transaction ref. No. ______________________ Date of transaction ___________ Or D.D. No. & Date _________________ Amount __________________ Valid till __________________

###### Regional Science Centre

Recent passport size photograph of the candidate.

## (National Council of Science Museums) Jawahar Nagar, Khanapara, Guwahati-781022

Form of application f or the use of candidates for appointment by Selection ( To be f i l l ed i n candidates' own handwriting and f orwarded to the above address)

1. Post applied f or:
2. Name i n f ull (i n Block letters)
3. Address:	a) Present
b) Permanent
c) Email ID
d) Mobile No.
4. Date and place of birth: ( i ) Date : ( i i ) Place :
5. Are you ( a) a citizen of India by birth and/or by domicile? YES/NO OR ( b) a person having migrated f rom Pakistan or YES/NO Bangladesh or other countries with the i nten- tion of permanently settling i n India or a subject of Nepal?
6. Name of the State to which you belong:
7. Father's /Husband's Name : Occupation : Address :
8. Is ( or was) your f ather: ( a) citizen of India by birth and/or by domicile? YES/NO ( b) A person having migrated f rom Pakistan or Bangladesh or YES/NO other countries with the i ntention of permanently settling i n India or a subject of Nepal?
9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO
A	9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO Are you physically handicapped? I f yes, give details Are you an Anglo I ndian? Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim Religion
9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO Are you physically handicapped? I f yes, give details Are you an Anglo I ndian? Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim Religion D C B	9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO Are you physically handicapped? I f yes, give details Are you an Anglo I ndian? Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim	YES/NO
9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO Are you physically handicapped? I f yes, give details Are you an Anglo I ndian? Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim Religion D C	9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO Are you physically handicapped? I f yes, give details Are you an Anglo I ndian?	YES/NO
9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO Are you physically handicapped? I f yes, give details Are you an Anglo I ndian? Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim Religion D	9. State your A Religion B Are you a member of Schedule Caste or Tribal ( H) or Aboriginal Community or Backward Class ? Answer ' Yes' or YES/NO ' No' and i f the answer i s ' Yes' give particulars and attach a certificate f rom the Regional Authorities i n support of your claim C Are you an Anglo I ndian? YES/NO D Are you physically handicapped? I f yes, give details YES/NO Are you physically handicapped? I f yes, give details	YES/NO

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