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Staff Selection Commission: Combined Higher Secondary (10+2) Level Examination 2018

The document is a registration form for the Combined Higher Secondary (10+2) Level Examination 2018 from the Staff Selection Commission. It provides personal details of the applicant such as name, date of birth, address, education qualifications. The applicant is Sayantan Choudhury, born on January 21, 1996 from Agartala, Tripura with a BSc degree. He is seeking to take the exam in Agartala and declares that all information provided is true.

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28 views

Staff Selection Commission: Combined Higher Secondary (10+2) Level Examination 2018

The document is a registration form for the Combined Higher Secondary (10+2) Level Examination 2018 from the Staff Selection Commission. It provides personal details of the applicant such as name, date of birth, address, education qualifications. The applicant is Sayantan Choudhury, born on January 21, 1996 from Agartala, Tripura with a BSc degree. He is seeking to take the exam in Agartala and declares that all information provided is true.

Uploaded by

Anonymous o53I1qEC
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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STAFF SELECTION COMMISSION

BLOCK NO. 12, CGO-COMPLEX, LODHI ROAD, NEW DELHI


110003

COMBINED HIGHER SECONDARY (10+2) LEVEL


EXAMINATION 2018

REGISTRATION NO: 81000132076

APPLICATION IS PROVISIONALLY ACCEPTED


1. NAME AS PER
2. NEW/CHANGED
MATRICULATION 3. FATHER'S NAME 4. MOTHER'S NAME
NAME
CERTIFICATE
SAYANTAN CHOUDHURY - TAPAN CHOUDHURY SUNANDA CHOUDHURY
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2019 7. GENDER
21/01/1996 23.5 MALE
9.1 .IF YES, TYPE OF
9. WHETHER PERSON WITH
8. CATEGORY DISABILITY (OH, HH,VH,
DISABILITY (PWD) ?
OTHERS)
SC NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA BIRTH MARK IN SHOULDER
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
CENTRAL BOARD OF SECONDARY EDUCATION
7180394 2013
(CBSE)
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )
AGARTALA (5601) GUWAHATI (DISPUR) (5105) SHILLONG (5401)
17. WHETHER 12th STANDARD PASS IN SCIENCE STREAM WITH
16. MEDIUM OF TYPE TEST MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR
EQUIVALENT (FOR C&AG AS DATA ENTRY OPERATOR)
ENGLISH NO
18.1. HAVE YOU ALREADY
JOINED A CIVIL POST BY 18.3. DATE OF DISCHARGE
18.WHETHER EX- 18.2. LENGTH OF SERVICE IN
AVAILING BENEFIT OF FROM ARMED FORCES
SERVICEMAN (ESM)? ARMED FORCES ( IN YEARS )
RESERVATION FOR EX- (DD/MM/YYYY)
SERVICEMAN (ESM) :?
NO - - -
19.1 DO YOU SUFFER FROM CEREBRAL-PALSY:
-
19.2 DO YOU HAVE A PHYSICAL LIMITATION TO WRITE AND SCRIBE IS REQUIRED TO WRITE ON YOUR BEHALF
(CERTIFICATE TO THIS EFFECT FROM THE CHIEF MEDICAL OFFICER/ CIVIL SURGEON & MEDICAL
SUPERINTENDENT OF A GOVERNMENT HEALTH CARE INSTITUTION AS PER NOTICE OF THE EXAMINATION
WOULD BE REQUIRED AT THE TIME OF EXAMINATION)?
NO
19.5 IF SCRIBE IS TO BE
19.4 WILL YOU MAKE YOUR OWN
19.3 WHETHER SCRIBE IS REQUIRED ARRANGED BY SSC, INDICATE
ARRANGEMENT OF SCRIBE?
MEDIUM
NO - -
20. WHETHER SEEKING AGE RELAXATION? 20.1 IF YES,INDICATE CODE
NO -
21. EDUCATIONAL QUALIFICATION
B.SC.

22. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?

-
23. DO YOU WANT TO MAKE AVAILABLE YOUR PERSONAL INFORMATION FOR ACCESSING JOB OPPORTUNITY IN
TERMS OF DoP&T'S O.M NO.39020/1/2016-ESTT.(B) DATED 21.06.2016 ?
YES

ADDRESS DETAIL
24. POSTAL ADDRESS 25. PERMANENT ADDRESS
85 JAGANNATH BARI ROAD 85 JAGANNATH BARI ROAD
AGARTALA P/O TRIPURA WEST AGARTALA P/O TRIPURA WEST
DISTRICT: WEST TRIPURA DISTRICT: WEST TRIPURA
STATE: TRIPURA STATE: TRIPURA
PIN: 799001 PIN: 799001
MOBILE NO : 7248673570 EMAIL ID : [email protected]
SIGNATURE

FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE


EXEMPTED - - -
DECLARATION
1. I HAVE READ THE NOTICE OF THE EXAMINATION AND ACCEPT ALL THE TERMS & CONDITIONS OF
THE NOTICE OF THE EXAMINATION.

2. I HEREBY DECLARE THAT ALL 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 OR AFTER THE EXAMINATION, MY CANDIDATURE/ APPOINTMENT IS LIABLE TO BE
CANCELLED.I AM WILLING TO SERVE ANYWHERE IN INDIA.
PRINT TAKEN ON: 05/03/2019 12:36:39 PM

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