Zilla Panchayath

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Zilla Panchayath, BAGALKOTERural Development and Panchayath Raj Department

Government of Karnataka

Acknowledgement SlipReference No 289033

Post applied forPANCHAYATH DEVELOPMENT

OFFICER

District opted for appointment BAGALKOTE

Place of Examination BAGALKOTE

Full Name( as in SSLC/10th Cert) MAHESHWARI BIDARIMATH

Mother's Name SHANTA

Father's Name CHANDRASHEKARAYYA

Gender Female

Date of Birth 01/06/1977

Applied Category 3BDo you come under these groups? KMS

Are you in Govt. Service? No

Do you claim age relaxation? Not Applicable

Are you a Graduate? Yes

Address for communication

C S BIDARIMATH, VIDYACHETAN ,

RAMDEV GALLI, JAMAKA

BAGALKOTE

District BAGALKOTE PIN 587301

Email address [email protected]

Landline Phone No 221267

Mobile Phone No 9986158495

Medium of writing test English

I hereby declare that all contents made in this application are true, complete and

correct to the best of my knowledge and belief. I have read the rules and understand that in the event of

any information being found false or ineligibility being detected before or after the selection ,action can

be taken against me by the Government under rule 20 of Karnataka Civil Services(General

Recruitment) rules 1977 as amended from time to time.

I have read the rules and instructions carefully and hereby undertake to abide

by them. I further declare that, I fulfill all the eligibility conditions regarding age, education

qualifications, reservations etc., wherever applicable,prescribed for the post. Place :BAGALKOTE

Date :06/08/2009 Signature of the Candidate



LAST DATE OF CHALLAN PAYMENT AT BANK: 11.08.2009

Challan Challan

Zilla Panchayath, BAGALKOTE

Rural Development &

Panchayat Raj Dept.

Government Of Karnataka

Candidate Copy

bank useonly

Bank and

Branch Name

Bank Journal No

Bank Journal

Date

PostApplied For

PANCHAYATHDEVELOPMENT OFFICER

District

opted for

appointment

BAGALKOTE

Ref No 289033

NameMAHESHWARI

BIDARIMATH

Address

C S BIDARIMATH,

VIDYACHETAN , RAMDEVGALLI, JAMAKA

BAGALKOTE,BAGALKOTE

Paid into the Credit of Secretary RDPR

A/C No 64044930154 , State Bank of

Mysore , Vidhana Soudha , B'lore

Sl No Particulars Amount1 Application Fee 500.00

Total 500.00

Amount in Words: Five hundred only

Signature of

Zilla Panchayath, BAGALKOTE

Rural Development &Panchayat Raj Dept.

Government Of Karnataka

Bank Copy

bank useonly

Bank and

Branch Name

Bank Journal No

Bank JournalDate

Post

Applied For

PANCHAYATH

DEVELOPMENT OFFICER

Districtopted for

appointment

BAGALKOTE

Ref No 289033

NameMAHESHWARIBIDARIMATH

Address

C S BIDARIMATH,

VIDYACHETAN , RAMDEV

GALLI, JAMAKABAGALKOTE,BAGALKOTE

Paid into the Credit of Secretary RDPR

A/C No 64044930154 , State Bank of

Mysore , Vidhana Soudha, B'lore

Sl No Particulars Amount

1 Application Fee 500.00

Total 500.00

Amount in Words: Five hundred only

Signature of

Remitter/Applicant



Remitter/Applicant

Received the above amount in Rs(in words)

Five hundred only

Date :Signature of

Receiving

authority

Accepted at all the Branches of SBM. (Incase of non availability of SBM then SBI or

SBH)

No bank charges to be collected from the

remitter/applicant

Received the above amount in Rs(in words)

Five hundred only

Date :Signature of

Receiving

authority

Accepted at all the Branches of SBM. (In

case of non availability of SBM then SBI or SBH)

No bank charges to be collected from the

remitter/applicant

Pr int Ba ck

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Zilla Panchayath