Central Establishment (Recruitment)

Surat Municipal Corporation 5th Floor, New Annexe Building,

Application Form Surat Municipal Corporation Main Office,
Muglisara, Surat - 395003

Application No. : 0189/010723/196/134016

Designation Code & Name : 196 - Environment Engineer

Post Applied for 'Environment Engineer'

1. First Name : HIMANSHUKUMAR

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2. Father/Husband Name : TUKARAMBHAI

3. Surname : PAWAR

4. Present Address : NISHAL FALIYAAT POST MANAICHONDHI TA DHARAMPUR DIST

VALSAD DHARAMPUR DHARAMPUR, VALSAD, VALSAD - 396051.
GUJARAT

5. Permanent Address : NISHAL FALIYAAT POST MANAICHONDHI TA DHARAMPUR DIST

VALSAD DHARAMPUR DHARAMPUR, VALSAD, VALSAD - 396051.
GUJARAT

6. Residence Phone No. : -

(With STD)
7. Mobile No. : 8758100512

Whatsapp No. (If Available) : 8758100512

8. E-mail ID : [email protected]

9. Gender : MALE

10. Date of Birth : 14/10/1998

11. Category : ST

12. Person with Disabilities : No

13. Marital status : Unmarried

14. Blood Group : -

15. a. Driving licence No : -

b. Driving licence Type : -

c. Licence issue state : -

d. Licence renewal date : 31/12/1899

e. Licence issue date : 31/12/1899

16. Pan No. : GTEPP9311L

17. Aadhar Card No. : 683285456398

18. Voter Identity No. : SSR1863851

19. If applicant is dependent of Municipal employee, give the following details :

a. Name of employee : -

b. Designation : -

c. Employee No. : -

d. Relation of the applicant : -

with the employee
20. If applicant is SMC employee/trainee give employee details :

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a. Employee No. : -

b. Employee Type : -

21. Mother tongue of applicant : Gujarati

22. Height : 159 Weight : 54

23. Give the following details of languages that you know.

Name of the Language Examination Passed if any Read Write Speak

English HSC √ √ √
Hindi 9th √ √ √
Gujarati SSC √ √ √

24. Educational Qualification :

Name of the Examination Passing Main Subject Score Per(%) Obt. Attempt Remarks
Institute/ Passed & Actual Month/ Type obtained Marks &
Board/Universit Degree Year Out Of
Marks

GUJRAT MASTER OF 07/2022 ENVIRONMETAL GPA 80.60 1 % = (GPA-

TECHNOLOGYCAL ENGINEERING ENGINEERING (8.56 - 0.5 )10
UNIVERSITY (M.E.) - )
ENVIRONMENT

GUJRAT BACHELOR OF 09/2020 ENVIRONMENT GPA 67.20 1 % = (GPA -

TECHNOLOGICAL ENGINEERING ENGINEERING (7.22 - 0.5)10
UNIVERSITY (B.E.) - )
ENVIRONMENT

25. Details of Experience : Total Experience: 1 Year(s) 6 Day(s)

Name of Designation Monthly Experience

From To Date
Institute & Nature of Work Salary in
Date Year(s) Day(s)

GUJRAT THEMIS BIOSYN 01/07/2022 01/03/2023 TRAINEE CHEMIST IN ETP 14000 0 244
LIMITED DEPARTMENT

GUJARAT POLLUTION CONTROL 10/03/2023 14/07/2023 TRAINEE PROJECT ASSOCIATE 18000 0 127
BOARD

26. Document : (At the time of verification, tick marked document is to be submitted)

Sr.No Document Detail

1 School Leaving Certificate [a]

2 Caste Certificate [a]

3 Graduation Marksheet [a]

4 Graduation Certificate [a]

5 Post Graduation Marksheet [a]

6 Post Graduation Certificate [a]

7 Course on Computer Concepts (CCC) [a]

8 Any other certificate related to Computer Education [a]

9 Percentage Conversion Certificate (CGPA/CPI/GRADE/SPI etc.) [a]

10 Aadhaar Card [a]

11 Permanent Account Number (PAN) Card [a]

 DECLARATION

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I hereby declare that the particulars furnished in application are correct and if information or
proof provided by me is found incorrect/fake or manipulated my candidature stands disqualified and
I will liable to be dismissed, if appointed.

PLACE : VALSAD

DATE : - Signature of the Applicant