PART-A

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A) PERSONAL INFORMATION

1Name in full

.2	Whhl
. 3	eter c u r r e n t y ( )Pt DesiiI	w o r k i n g															Retired
4	resengnaton: (nca s e o f re t i re d persons,post held at the time ofretirement)Offitt/DeparSlf P
5	ce men
6	cae ott	D D -M M -Y Y																										Y	Y
7	e orayDaf Bihhldf
8	Age as on te ast ate osubmission ofapplication(05/06/2017)Naili	____ Years ____ Months ____ Days
9	tonatWhhbli
10	yeter eongng toBackward category ( )SCSTVJ A NTB	Y e s																	No
11	[//()/NT(C)/NTDSBC/OBC]Fll AddOffi
	uress ce()
	T
	b NoMoel No
	Email
	Resid
	ence
	T
	b NoMoel No
	Email
12	PEll	lif id
	resenmoumens or asemoumens n case oreBasiPR st tt tretpersonay
	cDearness Pll		R s
	aowanceSial Pif		R s
	HRA ay /pecay any		R s
	..Oher All		R s
	towances Tl		R s
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B) QUALIFICATION (as on 05.06.2017)

Year of

Class % of

Educational

Total

Nature of jb

Achievement

QualificationAcadi	Degree	University/Institute		Passing	Marks obtained/
emc
P
roessonafil
attDetailf affiliiih	N a m e
s oon wProfess onal Bodies/Instituton/Society	M e m b e r s h i p N oS i n c e W h e n

Nor	Scale of Pay	ce	eroFT		EienceYMonhxpert		o
			rom	o	ears	s

C) EXPERIENCE (as on 05.06.2017)

Details of posts held from time to timeS

Post held & OffiPid

D) TRAINING

Details of training undergone in India and abroadName of

Institute

Period Nature of

trainiprogramng	where trainingwas received	of training	training

E) FOR PRIVATE SECTOR EXECUTIVES:

il turnover of last ng preseny

iiDetails of ition held Board level

)	three years of Company where workitlAverage & annua

)	pos
		/
i)
i	ttDetailf Sk Ehlii
i	s oocxcange sng

Below Boar

F) List of Publication/ Academic honors received :

d Level

G) If selected, minimum time required for joining the post : H) Any other information :

Date : Place : Signature

Note: Copies of testimonials in support of age, qualifications, experience etc. may be furnishedwherever necessary.

PAR T -B ( In case of Deputation )

Name of the Organization:

It is certified that:

1. The date of birth, qualification, experience and other details given byShri............, in PartA have been verified and found correct.
   
   
2. The integrity of Shri.. .................... is beyond doubt.
   
   
3. No vigilance or disciplinary proceeding is pending or contemplated against the officer concerned.
   
   
4. The MSEB Holding Company will be informed at the earliest, if any vigilance or disciplinary proceeding is initiated or contemplated against the officer, after his / her application is forwarded.
   
   
5. Up-to-date ACR dossier of the concerned officer is enclosed herewith.
   
   
6. It is certified that Shri............ would be allowed to retain lien in his regular post of.................... during the period of his appointment as Director on deputation basis.
   
   

Organisation Ref. No. Date:

Signature of the Authorized Officer (Name & Designation) Seal of the Officer

Date :

Place :

Full address of the Authorized Officer (With telephone/ Fax No.)