2/11/2018

Uttar Pradesh Police Recruitment and Promotion Board,

Lucknow
उ तर दे श पु लस भत एवं ो न त बोड, लखनऊ

I Declare that I have Read the detailed User Manual & Notification.

Notification Details ( Examination )

Advertisement/Notification Number : PRPB-ONE-1(112)/2017 /
UTTAR PRADESH POLICE DEPARTMENT /Constable
Department/Post Name :
Civil Police and Constable PAC Direct Recruitment 2018
Application ID : 009160105009602
Registration No. : 10511963169
Candidate's Personal Details
Father's Name
Candidate's Name : KM REETA DEEP SINGH
:
SURAJ
Mother's Name : Citizenship : Citizen of India
MUKHI
Domicile of
Female
Gender - Date of Birth : UP? / Yes /OBC
-10/08/1996
Category :
Aadhaar(UID) 380247228919
Are you Married ? : No Number I agree to use my aadhaar number to authenticate my identity
(Optional): from UIDAI.My identity information would only be used for e-KYC
verification for the purpose of authentication.
Mobile Number/ Email-ID : 9621819801 /kmreeta209728@gmail.com
Candidate Domicile Certificate Details (If you are domicile of Uttar Pradesh you are required to produce domicile certificate at the time of document verification to claim
any reservation/ relaxation admissible)
A (i) Domicile Certificate Issuing UP State
sdm
authority
A (ii) Date of Issuing Domicile Certificate (DD/MM/YYYY) 06/02/2018
A (iii) Domicile Certificate Serial No : 303182003055
Candidate Category (OBC/SC/ST) Certificate Details
B (i) Category Certificate Issuing UP State authority tahseeldar
B (ii) Date of Issuing Category Certificate (DD/MM/YYYY) 05/02/2018
B (iii) Category Certificate Serial No : 303183002847
Bank Transaction Details
State Bank Of Rs. 400.00 , CPC9357974
Bank Name - Payment Mode : Fees, Transaction ID - Date:
India - INB -11/02/2018 -
Other Details of Candidate
Dependent of Freedom Have you served as UP Home Guard for a minimum
No No
Fighter? period of 03 years and having required certificate?
0 - 0 -
Ex. Service Man? No Service Duration for Ex-service man (Day-Month-Year) :
0
Retirement Date for Ex-
Are you a U P Government Employee and having
service man // No
required certificate:
(Date/Month/Year) :
Service Duration for Government employee (Day-
0 0 0
Month-Year) :

Educational Qualification
Year
Name of Board/ Roll
Name of Examination Acquired(Y/N) Of
Institute/University Number
Passing
1 10th standard by board established by law in India or a UTTAR PRADESH BOARD OF HIGH
qualification recognized by the government as equivalent Yes SCHOOL AND INTERMEDIATE 2011 1581216
thereto EDUCATION
2 12th standard by a Board established by law in India or a UTTAR PRADESH BOARD OF HIGH
qualification recognized by the Government as equivalent Yes SCHOOL AND INTERMEDIATE 2013 1137863
thereto. EDUCATION
1/3
2/11/2018

Preferential Qualifications:-
Preferential Qualification Details
Qualification Acquired
1 Obtained O LEVEL Certificate in Computer from DOEACC or NIELIT Society No
2 Served in the Territorial Army for a minimum period of two years No
3 Obtained a B certificate of National Cadet Corps No
Home State UTTAR PRADESH
Home District KANNAUJ
Order of Post Preference 1-Constable Civil Police
“Candidates will be considered only for those posts for which he has applied and given preference”

↓ Address Details ↓ Candidate's Permanent Address Candidate's Correspondence/Mailing Address

Name (C/O) DEEP SINGH DEEP SINGH
House no./Village : NAGLA MAKK NAGLA MAKK
Street No./Post Office : GULARIYAPUR GULARIYAPUR
Locality/ Kasba/City: TIRWA TIRWA
State / District Name : UTTAR PRADESH /KANNAUJ UTTAR PRADESH /KANNAUJ
Police Station : SAURIKH SAURIKH
PIN : 209728 209728

घोषणा Declaration
1. म एत वारा घोषणा करता हूं क मने पर ा हे तु नगत व तत
ृ सच
ू ना/ व ि त जो क वेबसाइट http://prpb.gov.in पर उपल ध है , म उि ल खत सभी ावधान को यान से पढ़
लया है तथा उन ावधान का पालन करने का वचन दे ता/दे ती हूँ ।

I hereby declare that I have read all the provisions in the detailed notice/notification available on website http://prpb.gov.in of the examination carefully and hereby
undertake to abide by them.

2. म घोषणा करता हूँ क म रा यता, आयु सीमा, शै क यो यता इ या द क यथा न द ट पा ता क सभी शत को पण ू करता/करती हूँ ।
I declare that I fulfil all the conditions of eligibility regarding nationality, age limits, educational qualifications etc. as prescribed.

3. म घोषणा करता/करती हूँ क अनस

ु ू चत जा त / अनस
ु ू चत जनजा त के उ मीदवार के प म आर ण के लए मेरा दावा स य एवं सह है तथा म सच
ू ना/ व ि ते म दए गए
ा प म जा त माण प धा रत करता/करती हूँ ।
I declare that my claim for reservation as SC /ST candidate is true and correct and I am in possession of caste certificate in the prescribed format given in the
notice/notification .
OR
म घोषणा करता/करती हूँ क ओबीसी उ मीदवार के प म आर ण के लए मेरा दावा वा त वक एवं सह है तथा म सच
ू ना/ व ि त म दए गए ा प म जा त माण प जो
दनांक 01/04/2017 के बाद का नगत है ,धा रत करता/करती हूँ । म यह भी घोषणा करता हॅू क म उ0 0 सरकार वारा नगत आदे श सं या 13/22/16/92/TC-iii-का-2/2014
दनांक 17.12.2014 म व ण त ओबीसी ेणी के मी लेयर (creamy layer)से संबं धत वग से नह ं हूँ ।
I declare that my claim for reservation as OBC candidate is true and correct and I am in possession of caste certificate which is issued after 01/04/2017 in the
prescribed format given in the notice/notification. I also declare that as per Govt. order No.13/22/16/92/TC-iii-का-2/2014 dated 17.12.2014, I do not belong to the
category(creamy layer) mentioned therein.

4. म यह घोषणा करता हूँ क (शाद शद

ु ा पु ष अ यथ हे त)ु मेर एक से अ धक जी वत प नी नह ं है या (शाद शद
ु ा म हला अ यथ हे त)ु म यह धोषणा करती हूँ क मने कसी ऐसे
पु ष से शाद नह ं क है िजसक पहले से ह एक जी वत प नी है ।
I declare that I have no more than one wife living (For Married Male) OR I declare that I have not married a man already having a living wife (For Married Female).

5. म यह भी घोषणा करता/करती हूँ क मझ ु े व ध वारा था पत कसी भी यायालय के वारा कभी भी दोषी नह ं ठहराया गया है ।
I also declare that I have never been convicted by any court of law.

6. म यह भी घोषणा करता/करती हूँ क मझ ु े सरकार सेवा से कभी भी बखा त अथवा हटाया नह ं गया है तथा न ह प रवी ा अव ध के दौरान मेर सेवाओ को समा त कया गया है ।
I further declare that I have never been dismissed or removed from Govt. Service or my service been terminated during probation.

7. म एत वारा घोषणा करता/करती हूँ क इस आवेदन प म क गयीं सम त वि टयां / कथन मेरे ान और व वास के अनस
ु ार वा त वक, पण
ू और सह ह तथा मै नधा रत
नयम /अ धसच
ू ना के अनस
ु ार पा ता के सभी मानदं ड को परू ा करता /करती हूँ| कसी भी सच
ू ना के झूठा या गलत पाये जाने अथवा अपा ता क ि थ त म, मेरे चयन से पव
ू या
चयन के उपरा त कभी भी नयम के अनस
ु ार बोड मेरे व कारवाई कर सकता है , य द यह पता चलता है क मने कसी भी मु े पर बोड या नयिु ि त ा धकार को गुमराह कया
है , तो इसके लये म परू तरह से वयं िज मेदार होऊँगा िजसम अ य द डा मक कायवाह के साथ व धक कायवाह भी सि म लत होगी तथा उसके प रणम व प सभी दं ड का
भागी होऊँगा ।
I hereby declare that all the entries/statements made in this application are true, complete and correct to the best of my knowledge and belief and I fulfill the
eligibility criteria as per the relevant rules/notification. In the event of any information being found false or incorrect or ineligibility being detected before or after
selection the Board or appointing authority can take action against me as per rules in case it is detected that I have mislead the Board on any issue and I will be solely
responsible for all penal consequences thereof, including but not limited to penal action under the law.
I accept the above declaration : Yes

2/3