Department of Agriculture Government of West Bengal Application Form Post Applied For :____________________________ Full Name (in block letter) :_____________________________________________________________ Name of Father / Husband :_____________________________________________________________ Date of Birth :______/______/__________Religion :_____________________________ Category : SC /ST /OBC /EXSM / PH ( Please Tick mark ) Sex :_____________Nationality:______________________________________ Permanent Address :_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Mobile & E-male Address : Educational Qualification : Name of Board / Council / University Year of Passing Full Marks Obtained Marks % of Marks CLASS - X CLASS - XII GRADUATE Declaration I Shri/Smt ________________________________________________declare that all statements made in this application are true, complete and correct to the best of my knowledge and belief and in the event of any information found false, my candidature is liable to be cancelled. Date: Yours Faithfully, Place: ________________________ (Signature of the Applicant) [Affix recent Pass port size photograph] Application No: 102475485