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CAUTION
(i) A candidate must consult the “Information To Candidates” for the examination, use the prescribed application format and fill in the
application form correctly against all the items in his/her own handwriting with ball point pen of black/blue ink and furnish required
particulars/documents. If any item(s) of the application is considered inapplicable to the candidate he/she should write ‘NOT APPLICABLE
or (N.A.) ’ against the particular item(s) and in any case no item of the application should remain unfilled.
(ii) Correction/overwriting, if any, should be accompanied by signature of the candidate.
(iii) In case the application is not filled in accordance with the above instructions or any of the required documents is not enclosed, it will be
treated as incomplete/defective and summarily rejected.
Note : Keeping the application form in front, the requisite documents are to be stitched with the
application securely with a durable thread in the following sequence – (1) I.P.O. or Treasury
Challan, in original (not required for SC/ST candidates of W.B. and Persons with Disability), (2)
Self-attested photocopies of (i) Madhyamik or equivalent qualification certificate, (ii) Law
Degree certificate (iii) Certificate of enrolment in the roll of Bar Council, (iv) SC/ST/BC/PH (if
applicable), (v) Citizenship Certificate (for candidates acquiring citizenship by registration) and
(3) Two unstamped Self-addressed envelopes.
PUBLIC SERVICE COMMISSION, WEST BENGAL
APPLICATION FORMAT
APPLICATION FOR WEST BENGAL JUDICIAL SERVICE EXAMINATION, 2012
ADVERTISEMENT NO. 01/2012
( CLOSING DATE FOR RECEIPT OF APPLICATION : The 12th March, 2012. )
To
The Deputy Secretary (Examination),
Public Service Commission, West Bengal.
Sir,
I intend to appear at the West Bengal Judicial Service Examination, 2012. Necessary particulars are furnished
below :-
1. Name of the candidate in full (IN CAPITAL LETTERS) :
2. (a) I.P.O./Treasury Challan attached for : Rs.______________
(b) I.P.O. No(s). and value :
(c) Date of purchase and name of issuing :
post office with address
(d) No. and amount of receipted :
Treasury Challan attached
(Space for office use )
Roll No.
Space for pasting recent
passport size photograph
signed in full by the
candidate
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3. Choice of Preliminary Examination Centre : Centre name
(Kolkata or Darjeeling )
4. (a) Indicate your community : Genl. SC ST BC
(Put a ‘ ’ mark in appropriate box/boxes). A B
SC/ST/BC candidates not belonging to the
State of West Bengal should indicate their
community as ‘General’. [ SC/ST/BC candidate
shall attach self-attested photocopy of certificate(s) ]
(b) If SC/ST/BC, mention your Sub-caste, the : Sub-Caste State Issuing Authority
name of the State from which SC/ST/BC
certificate obtained and the designation of
issuing authority.
5. (a) Whether you are a person with disability, (write :
‘Yes’ or ‘No’) [If yes, attach self-attested
photocopy of P.H. certificate]
(b) State the category of disability : Low Hearing Orthopaedically
(Put ‘ ’ mark in the appropriate box) Vision Impaired Handicapped
(c) In case, you are a low vision candidate : Yes No
mention if you require the help of a Scribe
(Put ‘ ’ mark in the appropriate box)
6. S E X (Put ‘ ’ mark in appropriate box) : Male Female
7. (a) Date of birth (as recorded in Madhyamik or : Date Month Year
equivalent examination certificate) [attach
self-attested photocopy of Madhyamik or
equivalent examination certificate]
(b) Do you claim relaxation of age as SC/ST/BC :
of West Bengal or as Person with Disability
[ Write ‘Yes’ or ‘No’ ]
(c) Do you claim relaxation of age limit for being :
a Government Servant ? (Write ‘Yes’ or ‘No’)
[ If yes, attach original certificate from the
appointing authority ]
8. (a) Whether a citizen of India :
(Write ‘Yes’ or ‘No’)
(b) State, whether a natural citizen or a citizen by :
registration (If by registration, attach selfattested
photocopy of certificate)
9. Father’s Name :
10. Address (IN CAPITAL LETTERS) mentioning
Post Office, Sub-Division, District and Pin Code
(a) Postal Address :
(b) Permanent Address :
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11. (a) Do you have the ability to read, write and :
speak in Bengali (Write ‘Yes’ or ‘No’)
(b) (i) Whether you are a Nepali speaking person :
from the three hill sub-divisions of Darjeeling
District, viz., Darjeeling Sadar, Kalimpong and
Kurseong. (Write ‘Yes’ or ‘No’)
(ii) if yes, mention the sub-division :
(c) State your mother tongue :
(d) State your choice of language in case you do not : Hindi Urdu Nepali
take up Bengali in compulsory Paper-II of Final
Examination (Put a ‘ ’ mark in appropriate box)
12. Academic Qualifications (Madhyamik and onwards) :
[ Self-attested photocopy of all certificates must be attached to the application ].
Name of Examination passed Name of Board/Council/University Division/
Class
Year of
passing Remarks
13. Whether you are enrolled as an advocate in the roll :
of Bar Council of any State or Union Territory in
India on the date of advertisement for the exam.
(Write ‘Yes’ or ‘No’)
[ If yes, attach self-attested photocopy of certificate ]
14. (a) Were you debarred previously by the Commission :
from applying through this Commission for
appointment under Government ? (Write ‘Yes’ or ‘No’)
(b) If yes, give details : Year Examination Roll No.
15. (a) Are you presently employed? (Write ‘Yes’ or ‘No’):
(b) If yes, give details :
(1)
Name of the Post
(2)
Temporary/Permanent
/ on Contract basis
(3)
Full time/
Part time
(4)
Office where
employed
(5)
Date of
joining
(6)
Date of
leaving, if
any
(7)
Cause of leaving
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16. (a) Did you appear in the West Bengal Judicial Service :
Examination previously ? write ‘Yes’ or ‘No’
(b) If yes, specify years of examination and roll numbers : Year of Examination Roll No
17. State below the three optional papers (from the list : OPTIONAL PAPERS
given in the ‘Information to candidates’) in which you
intend to appear – (No addition or alteration in the
choice of optional papers thus indicated will be allowed
at any stage after submission of the application)
18. The list of documents enclosed :
i) ii)
iii) iv)
v) vi)
vii)
D E C L A R A T I O N
I solemnly declare that (a) 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 being found false my candidature will be liable to be cancelled,
(b) Original documents, certificates will be produced on demand, (c) I agree to take this examination at my own risk
subject to verification of my eligibility by the Commission and if subsequently the Commission finds me ineligible for
admission to the examination, the Commission may cancel my candidature even after finalization of the results. (d) I have
submitted no other application for this examination. *(e) I have informed the Head of my Office/Department in writing that
I am applying for this examination ( *Strike out if not applicable).
Yours faithfully,
Place :
Date :
(Full signature of the candidate)
(Full name to be written clearly)
[ Not in capital letters]
(1)
(2)
(3)
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