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This document is an application registration for the Combined Higher Secondary Level Examination in 2016. It provides details about the applicant such as name, father's name, date of birth, gender, nationality, category, address, contact information, and educational qualification. The applicant is seeking age relaxation and fee exemption as an OBC candidate with a physical disability and has applied for the post of PLDEC with English as the medium for the typing test. Photos and signatures of the applicant are also included.

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JR Saravanan

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0% found this document useful (0 votes)

219 views

Print Application Form Go To SSC Online Application Home Page

Uploaded by

JR Saravanan

Available Formats

Download as PDF, TXT or read online on Scribd

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Application Registration No: 63007180049 for the Combined Higher Secondary Level Examination - 2016
Your Application is Completed
1.& 2. Name of Computer Based written Examination Center and Code :
SR-Tiruchirapalli(8206)
SR-Chennai(8201)
SR-Madurai(8204)
3.Candidate Name :
R SARAVANAN
4.Father's Name :
K RATHINAM
5.Mother's Name :
R JAGADAMBAL
6.Date of Birth (dd/mm/yyyy) :
23/05/1981
7.Gender :
Male
8. Nationality :
Indian
9.Fee Exemption claimed :
Exemption Claimed
10.Category :
OBC
10.1.Whether Ex-Serviceman? :
No
10.2. For Ex-Serviceman-Length of Service(in years) :
10.2. Date of discharge (dd/mm/yyyy) :
10.3. Whether eligible for Ex-Serviceman Reservation? :
11. Whether PH (PWD) :
Yes
11.1. If yes, indicate code :
OH
11.2. Whether suffering from cerebral palsy? :
No
11.2. If VH/Cerebal Palsy candidate, whether scribe is required ?
11.3. if yes indicate medium :
12. Whether seeking Age relaxation? :
Yes
12. If yes, indicate code :
04-PH+OBC
12.1. Age(as on 01.01.2017) :
35.7
13. Preference for posts :
PLDEC
14. Indicate medium for Typing Test :
English
14.1. Do you possess knowledge of Typing Test ? :
Yes
15. Aadhar Card Number (If available):
16.Mark of Visible Identification :
ASM OVER THE RIGHT CHEST
17. Whether you belong to Religious Minority Community ? :
No
18. Educational Qualification :
MBA
19. Do you want to make available your personal Information for the accessing job opportunity in terms of DoP
Yes
& T's O.M.No. 39020/1/2016-Estt.(B) dated 21.06.2016 ? :
20.Postal Address :
4/19 KUDI STREET
Village/City :
VISVAMBAL SAMUTHIRAM SOUTH POST THURAIYUR T
District :
TRICHY
State :
Tamil Nadu
Pincode :
621003
4/19 KUDI STREET VISVAMBAL SAMUTHIRAM SOUTH P
21.Permanent Address :
THURAIYUR TK TRICHY DT
State :
Tamil Nadu
Pincode :
621003
STD Code :
Phone Number :
Mobile Number :
9535599553
Email ID :
[email protected]
23.Photo
24.Signature

Declaration

I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge
and belief. I understand that in the event of any information being found suppressed false or incorrect or ineligibility being
detected before and after examination, my candidature/appointment is liable to be cancelled.
Place:
Date (yyyy-mm-dd):2016-11-10
Signature of Candidate