For office use Only

Clerk. Entry No................./2023 Clerk Seat No..................

Affix latest passport size

Photograph and sign
across the same
in such a way that part
of the signature should
come on photograph and
the remaining part on
the application.

To,
The Registrar (Administration),
High Court of Bombay at Goa,
Penha-de-Franca, Porvorim – Goa.

Subject: Application for the post of Clerk.

1. Name of the Applicant : Mr/Mrs/Ms. Name Middle name Surname

(in Block letters)

2. Date and place of Birth : Date :

Place :
3. Age on the date of publication of : Years Months Days
the advertisement (YY/MM/DD)
4. Gender (Male/Female/others) :

5. Visible identification marks :

6. Full Address for correspondence :

(In block letters)

7. Permanent Address :

8. a. Whether the candidate belongs :

to Scheduled Caste/Scheduled
Tribe/Other Backward Classes/
Nomadic Tribe recognized by
the Government
b. Documents annexed in support :
thereof

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9. a. Marital Status :
(Married/Unmarried/Divorced)
b. If married, do you have-
i. more than one wife living (if :
a male)
ii. married a person having :
already a wife living (if a
female)
10. In case of change in name/surname, :
documents annexed in support of
change in name

11. Number of children as on the date of :

advertisement
12. a. Are you citizen of India? :

b. Documents annexed in support :

thereof
13. Mobile No. :

14. Email ID :

15. Aadhar No :

16. Valid Employment Exchange Reg. : Reg. No. Valid upto :

Number, if any

17. Valid residence certificate of 15 :

years residence in the State of Goa is
attached (YES or NO)
18. a. Mother tongue :

b. Other languages which the : Marathi Hindi English

candidate can speak and/or read
and/or write (YES or NO)
c. Knowledge of Konkani language :
(YES or NO)
d. Document attached as proof of :
knowledge of Konkani
19. a. Whether the applicant has any :
relatives in the Judiciary.

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 b. Give the details of relative with name, designation & relationship.

Name Org. Name Designation Relationship with

candidate

20. a. Whether the applicant is a :

Government employee.
b. Whether application is routed :
through proper channel.
c. Whether N.O.C. from parent :
department is annexed
21. Educational Qualifications :

Sr. SSC, HSSC, Board/ University Month & Marks Maximum Class/
No. Graduate, Year of obtained marks Percentage
Post Graduate & Passing
Law Graduate

(Note : May attach additional sheets, if required)

22. Professional Qualification :

Details of professional Speed w.p.m. Name of Authority/Institute issuing % or Grade

qualification Certificate achieved
a English Typing

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23. Details of Computer Course/s undertaken :

Name of Computer Duration in Name of Authority/Institute % or Grade

Course months/years issuing Certificate achieved
(Degree/Diploma/
Certificate Course)

24. Other Technical qualifications if any :

25. Work experience (if any) :

Sr. Name & address of Post held Date Total

No. the Employer From upto Period

(Note : May attach additional sheets, if required)

26. a. Is there any criminal or civil :

proceedings held/pending
against the candidate or whether
he/she was convicted by
Criminal Court or held guilty/
facing disciplinary enquiry/
proceeding?
(mention details)
b. if he/she has been convicted for an
offence involving moral turpitude
or is or has been permanently
debarred or disqualified by the
High Court or UPSC or any State
Service Commission, as the case
may be, from appearing in any
examination or selection process
conducted by it

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27. Details of two respectable persons who know the candidate and who have issued the
Character certificate in (Form B) on or after the date of publication of this
advertisement

Sr. Name Address Mobile Number

No.

28. 'e-challan' receipt Number with Date :

29. List of enclosures/documents :

(All annexed documents must be self
attested except Declaration and
character certificates [Forms A &
B] which should be original)

Dated: Name and Signature of Applicant

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 F O R M 'A'

(To be submitted in original)

D E C L A R A T I O N

1) I the applicant Mr/Mrs./Ms. _________________________________do hereby

declare that there is no criminal prosecution pending against me nor have I been held
guilty or convicted by a Criminal Court nor am I facing any disciplinary/criminal
enquiry. I have not been debarred by any Union or State Public Service Commission or
Government or Public Body from seeking Employment.

I do understand that in the event of particulars or information given herein being

found false or incorrect, my candidature for the post is liable to be rejected or canceled.
In the event of any information found to be false or discrepancies in the particulars being
detected after my appointment, my services shall be terminated without any notice to me.

2) I have _______ (Number of) living child/children as on today. Out of which the
number of child/children born after 28th March, 2005 is ___________________________
(mention dates of birth, if any).

I am aware that, if any total number of living children are more than two, due to
the children born after 28th March, 2006, I am liable to be disqualified for the same post.

I do hereby declare that all the entries made in the Application Form and the
aforesaid declaration are true and correct to the best of my knowledge and belief.

Place :-
Date :- Name and Signature of Applicant

Note: The above declaration should also be filled in and signed by unmarried candidate stating 'Not
Applicable' in respective cases.

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 F O R M 'B'

(To be submitted in original)

CHARACTER CERTIFICATE

Certified that, Mr./Mrs./Ms._________________________________son/daughter/

wife of Mr. ______________________ r/o ____________________________________
is well known to me since last __________ years. To the best of my knowledge and belief
he/she bears good moral character and has nothing adverse which debars his/her
suitability for Government job. He/she is not my relative.

Place : Signature__________________________
Date : Name_____________________________
Address ___________________________
__________________________________
Seal of the __________________________________
issuing Authority __________________________________
Mobile No ________________________

Note: The Character Certificate must be issued by the persons whose names are mentioned at Sr. No. 27 of
the application form.

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