/ Karnataka State Sericulture Research And Development Institute
THALAGHATTAPURA, BANGALORE – 560 109.
Application for Backlog Posts / Photo
A. Name of the Post :
B. No. and Date of the Advertisement
1. Name of the Candidate :
(in Block Letters)
2. Name of the Father/Husband or Guardian
with occupation and address.
3. Postal Address of the Candidate :
4(a)Date of birth (as entered in the SSLC/ Matriculation/SSC or Equivalent Examinations
Marks Card or Secondary School Leaving Certificate).
(b) Place of birth, Taluk, District and State.
5. Qualification / Month and Year of passing / Marks obtained in each year of the public Examination / Max. Marks Prescribed for the Examination. / Average percentage of marks obtained in public Examination. / Class and Rank if any.
  1. SSLC/
Matriculation, S.S.C.
  1. PUC or Intermediate

c. Graduation,
B.Sc. / B.Sc., Ag.
B.Tech (Textiles)
d. Post Graduation
(Subject)
e. Doctorate in
f. Any other
Additional
Qualification
g. Experience/
Training as
prescribed to
the post
6. Whether the Candidate belongs to:
(a) Schedules Castes
(b) Scheduled Tribes
7. Religion to which the candidate
belongs.
8. (a) Are you a Citizen of India by
birth or by domicile?
(b) If not what is your Nationality?
Furnish the relevant Certificate
in the Form Appended.
9. (a) Sex
(b) Marital Status
(c) If married, have you more than
one wife living?
(d) Have you married a person
already having a wife
10. Whether the copies of the
following documents are enclosed?
(a) SSLC (or equivalent examination)
Marks Card
(b) PUC Marks Card
(C) Marks Cards of all the other
Examinations (specified in Column 5).
(d) Service Certificate;
(e) Schedules Caste/Schedules Tribes
(Form- I)
(f) Crossed Indian Postal Order in Original
(g) Any other Certificate(s) that is /are
enclosed.
11. Ph.D., in the
a. Subject
b. Year of award of Doctorate
c. University
d. Thesis in which the Doctorate is awarded
12. Any other information the candidate
desires to furnish.

DECLARATION OF THE CANDIDATE

I do hereby solemnly and sincerely affirm that the statement made and the information furnished above are true. Should however be found that any information furnished herein is untrue in material particulars I realise that I am liable to criminal prosecution and I am also agreeable to forego the claim for public service.

Place:

Date:Signature of the Candidate.

CERTIFICATE BY FORWARDING AUTHROITY

Certified that Dr./Sri./Smt...... holds Permanent/Temporary post under the Sate/Central Government/Local Authority/Corporation owned or Controlled by the Government or any authority specified by Government as...... (designation) from...... having been appointed therto regularly under the rules of recruitment.

His/Her work and character so far as known to me are good. He/She is permitted to apply for the post sought for.

Signature and Designation

Department

ATTESTATION FORM I

  1. Name in full (In Capitals) with aliases if any

(please indicate names, if any, added orDropped

at any sate/any part of your name or surname______

  1. Present Address in full (i.e., House number

Lane, Street, Road, Village, Town, Taluk,

Dist. And Police Station)

  1. House address in full (i.e., Number/ Lane/Street, Road/Town, Village and Police Station

  1. Particulars of places (with periods of residence where you have resided for more than six months at a time during the preceding three years)

From To / Residential address in full (i.e. House Number, Lane/Street, Road, Town, Village, Police Station and District.
  1. Name of Father/Husband (please mention father/husband is alive or dead)
(a)Name in full with aliases if any.
(b)Present postal address (if dead, give last address)
(c)Permanent Home address
(d)Profession
(e)If in service give designation and other details.
  1. 6. (a) Place of birth, District and State in
  2. which situated
  3. (b) District and State present domicile

7. (a) Your Religion
(b) Are you a member of Schedule
Caste, Scheduled Tribe/Group-A,
B,C,D,E, or any other Caste.

8. Educational Qualifications showing places of education with years in school and Colleges since

15th year of age

Name of School/College with full address. / Date of
Entering / Date of Leaving / Examination passed
  1. If you have been employed at any time, give details as to:

Designation of the post held or designation of work / Period
From To / Full Address of the office:
Firm/Institution / Reasons for leaving the employment
10.(a) Have you ever been prosecuted/kept
under detention or bound down/
fined, convicted by a Court of law for
any office?
Is any case pending against you in any
Court of Law at the time of filling up of
this attestation form?
(b) If the answer is “Yes” full particulars of
the case, detention, fine, conviction,
sentence, should be given.
(1)(a) Have you ever been debarred from
appearing for public examination
by the University/Education
Department/Public Service
Commission,
(b) If the answer is ‘Yes’ full particulars
of the case should be given.
(2)(a) Have you ever been debarred or
excluded by the Public Service
Commission (s) Union/State from
appearing from Examination/
Selection/ conducted by them.
(b) If answer is ‘Yes’ the full particulars
should be given.
(3)(a) Have you ever been dismissed/
removed from service or debarred
from entry into Government
Service?
(b) If the answer is ‘Yes’ full particulars
of the case should be given.

I hereby declare that the foregoing information is correct and complete to the best of my knowledge.

I am not aware of any circumstance which might impair my fitness for employment at the K.S.S.R.D.I.

Place: Signature of Candidate.

Date:

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