APPLICATION FOR THE POST OF _______________
1. Mode of recruitment viz. Promotion / Deputation : ______________________________________
/ Direct Recruitment / Contract (whichever
applicable, please specify)
2. Name of the Candidate (in Block letters) : ______________________________________
3. Father’s/Husband’s Name : ______________________________________
4. (a) Date of Birth in Christian era
(in dd/mm/yyyy format) : ______________________________________
(b) Age as on last date for receipt of : …………. Years ……….. Months ……….. Days
applications
5. Permanent Address (with PIN code) : ______________________________________
______________________________________
______________________________________
6. Address for Correspondence (with PIN code) : ______________________________________
______________________________________
______________________________________
7. E-mail address, Phone Numbers (Office, : ______________________________________
Residence & Mobile) along with Fax Number, if ______________________________________
any
8. (a) Religion : ______________________________________
(b) Whether belonging to SC/ST/OBC, if yes, : ______________________________________
please specify
(c) Whether physically disabled, if yes, please : ______________________________________
specify
(d) Gender: Male / Female : ______________________________________
9. Details of Educational Qualifications from
Matriculation onwards (Enclose a separate
sheet, duly authenticated by your signatures, if
the space below is insufficient) :
Sl. No. (1) (2) (3) (4) (5)
a. Examination passed
b. Year of passing
c. Name of College / Institute
d. University / Board
e. Main subjects
f. Total aggregate & percentage of
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marks obtained, division and
remarks, if any
10. Details of experience (in chronological order). :
Enclose a separate sheet, duly authenticated by
your signatures, if the space below is insufficient
Sl. No. (1) (2) (3) (4) (5)
a. Name of organization
b. Type of organization (i.e. Central /
State Govt, Central / State PSU or
University or Autonomous Body, others
(please specify)
c. Post held and period of Post Held
tenure with dates (in From
dd/mm/yyyy format)
To
d. Whether permanent / regular or
adhoc or temporary or quasi-
permanent or deputation or contract
basis (Please specify)
e. Scale of Pay (Please indicate Grade
Pay, if pre-revised pay scale) /Level
in Pay Matrix and current basic pay
f. Whether scale of pay is on CDA
or IDA pattern or any other DA
pattern. Please specify
g. Nature of duties highlighting
experience required for the post
applied for
11. Whether Educational and other qualifications
required for the post are satisfied. (If any
qualification has been treated as equivalent to
the one prescribed in the Rules, state the
authority for the same) : ______________________________________
Qualifications/ Experience Qualifications/Experience possessed by the officer
Required for the post
Essential Education
Qualification:
Desirable Education
Qualification:
Essential Experience:
Desirable Experience:
12. In case the present employment is held on deputation / contract basis, please :
state
a) The date of initial b) Period of appointment c) Name of the parent d) Name of the post and
appointment on deputation / contact office / organization to pay of the post held in
which the applicant substantive capacity in the
belongs. parent organization
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Note : In case of officers already on deputation, the applications of such officers should be
forwarded by the parent cadre/department along with cadre clearance, vigilance clearance and
Integrity certificate.
13. (a) Whether the present pay scale in which you are working in your parent
department has been granted under Modified Assured Career Progression
Scheme (MACP), Assured Career Progression Scheme, Time Scale,
Personal Upgradation, Financial Upgradation, In-situ Upgradation, Non
Functional Upgradation, Non-functional Grade, Adhoc-promotion or any
other similar scheme of your parent department : Yes / No
(b) If yes, please specify the substantive pay scale of the post held by you
along with name of the post : ________________
________________
14. If working or belonging to the Public Sector Undertaking please indicate :
(a) The status of PSU. Whether Schedule A, B, C, D, etc. : ________________
(b) The Grade in which you are working along with the pay scale (Whether E- : ________________
1, E-2, E-3, E-4, E-5, E-6, E-7, E-8, or E-9, etc.)
(c) The grades and designations alongwith pay scales of the posts which are : ________________
below you in the officers / Executive cadre ________________
(d) The grades and posts alongwith pay scales which are above you in the : ________________
officers / Executive cadre upto the Board level ________________
15. If working in Department, other than specified in Sl. No. 14 above, please :
indicate
(a) The designations alongwith pay scales of the posts which are below you in : ________________
the officers / Executive cadre ________________
(b) The grades and posts alongwith pay scales which are above you in the : ________________
officers / Executive cadre upto top management level / head of the ________________
organization level
16. Are you in a revised scale of pay? If yes, give the date from which the revision : ________________
took place and also indicate the pre-revised scale along with the DA pattern ________________
applicable (Please enclose a self-attested copy of the latest pay slip)
17. Total emoluments per month now drawn:
Basic Pay in the PB / Pay Grade Pay / Level in Pay Total Emoluments
Matrix Matrix
18. Please indicate the present rate of DA and the date (dd/mm/yyyy format) from : ________________
which it is applicable ________________
19. Age of retirement applicable in parent department : ________________
20. Your date of retirement in the parent department : ________________
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21. Contact details of the officer(s) in personnel / HR / Admn. Deptt. who could be contacted regarding the ACRs
/ NOC / Vigilance / Discipline clearance, etc. (if there are different officers dealing with these matters,
please indicate their complete details, separately):
Name _________________________________
Designation : ____________________________
Address (with PIN code) : __________________
Tel.No./ Fax No.: _________________________
E-mail ID: _______________________________
Website : ________________________________
22. Additional Information, if any, which would you like to mention in support of : ________________
your suitability for the post (Enclose a separate sheet, duly authenticated by ________________
your signatures, if the space is insufficient)
23. Whether applied for the similar post in NHAI in the last one year, if so, please : ________________
indicate the post applied for, date of advertisement and date of interview, if any ________________
DECLARATION
I also hereby solemnly declare and undertake that all information furnished by me is true, correct and complete
to the best of my knowledge and belief. I undertake that, if at any stage of selection or even after selection, any of the
information furnished by me is found to be false, incorrect or misleading, then my candidature / appointment / services
will stand cancelled / terminated without assigning any reasons there for. Mere submission of application does not
confirm the candidature and the candidature shall remain provisional till the verification / certification of the details
furnished by the candidate.
Date : __________ Signature : ___________________________
Place: __________ Name : ______________________________
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VERIFICATION
(To be completed by the parent department)
It is certified that the particulars given by the candidate in his/her application, regarding the details of educational
qualification, relevant experience and pay particulars, etc. have been verified from the service records and are true, correct
and complete. In case of selection, it is confirmed that the officer shall be relieved within the time frame stipulated by NHAI.
2. Integrity Certificate: It is certified that integrity of the officer is beyond doubt.
3. Vigilance / Disciplinary Clearance Certificate: Certified that no vigilance case or disciplinary proceedings or
criminal proceedings are either pending or contemplated against the officer.
4. No Penalty Certificate: Certified that no minor or major penalty has been imposed on the officer during the last ten
years OR list of major / minor penalties imposed on the officer during the last 10 years is as under: -
Sl. Nature of Type of Penalty Date of Period of currency of Remarks, if any
No. penalty imposition penalty alongwith
(Major / Minor) of penalty date until the penalty
is valid
Date : __________ Signature : _______________________
Place : __________ Name : _______________________
Designation : _______________________
Address : _______________________
Tel. No. _______________________
Official seal : _______________________
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