Ccc Examination Registration from (Revised) Repeater

Extra REPEATER’S EXAM FORM Photograph CCC EXAMINATION REGISTRATION FROM (REVISED) REPEATER FOR REPEATER EXAM FOR EMPLOYEES OF STATE GOVERNMENT (Attach One extra Passport Size photograph with this form) NOTE : ALL INFORMATION SHOULD BE FILL IN ENGLISH CAPITAL LETTERS ONLY

1 NAME OF SECRETARIAT : 2 NAME OF DEPARTMENT : Attested 3 NAME OF INSTITUTE / OFFICE : Photograph 4 OFFICE ADDRESS : With Signature Of Head of Employee’s PHONE NUMBER – office

5 NAME AND DESIGNATION OF HEAD : OF INSTITUTE / OFFICE CONTACT NUMBER AND E-MAIL ADDRESS (M) (O)

6 NAME OF EMPLOYEE : SURNAME FIRST NAME LAST NAME

7 DESIGNATION : 8 GPF ACCOUNT NO : 9 DATE OF BIRTH : 10 AGE : 11 DATE OF JOINING : 11.1 IN GOVT. SERVICE : 11.2 DEPARTMENT : 12 DATE OF RETIREMENT : 13 PERMANENT RESIDENTIAL ADDRESS :

PHONE NUMBER - 14 SEX : 0 – MALE / 1- FEMALE 15 MARITAL STATUS : 0-UNMARRIED / 1- MARRIED / 2-DIVORCED / 3 - WIDOW 16 CASTE : 0-GENERAL / 1-SC / 2-ST / 3-OBC 17 PHYSICALLY HANDICAPPED : YES NO 18 EX-SERVICEMEN? : YES NO 19 ARE YOU PROMOTED BETWEEN 30 : YES NO SEP 2006 TO 31 MARCH 2007 20 IF NOT WHETER LIKELY TO BE : PROMOTED / HIGHER SCALE WITHIN 3 / 6 / 9 / 12 / NA MONTHS 21 TRIAL NO : 22 DATE OF LAST EXAM : 23 EXAM NO : 24 TYPE OF EXAM : 0 – DIRECT EXAM / 1 – AFTER TRAINING 25 IF AFTER TRAINING, TRAINING : FROM TO PERIOD 26 WHETHER EXEMPTED? : YES NO 27 IF YES, SUBJECT OF EXEMPTION : PRACTICAL THEORY 28 MARK RECEIVED :

SIGNATURE OF EMPLOYEE

SIGNATURE OF PRINCIPLE ITI, TARSALI. SIGNATURE OF HEAD OF EMPLOYEE’S OFFICE

ADMIT CARD NAME OF EXAM CENTER : TARSALI, ITI, VADODARA Attested DATE OF EXAMINATION : Photograph NAME OF EMPLOYEE : With Signature SEAT NUMBER : Of Head of TRIAL NUMBER : 1 (One) / 2 (Two) / 3 (Three) Employee’s office

SIGNATURE OF PRINCIPLE ITI, TARSALI. SIGNATURE OF HEAD OF EMPLOYEE’S OFFICE