wu APPLICATION RECEIVED (CONTENTS NOT VERIFIED) STAFF SELECTION COMMISSION BLOCK NO. 12, CGO-COMPLEX, LODHI ROAD, NEW, DELHI 110003, CONTRACTS) EXAMINATION, REGISTRATION NO: 10003428: JOR ENGINEER (CIVIL, MECHANICAL, ELECTRICAL AND QUANTITY SURVEYING & , 2022 293 NAME AS PER MATRICULATION | 2. NEW/ CHANGED 2 r reas 4 * 3, FATHER'S NAME 4, MOTHER'S ANANDHUJAVAKUMAR, s TAYAKUMAR PM. SARASW, 5 6. AGEAS ON, 5. DATE OF BIRTH (DD/MMIYYYY) o1Oiatias 7. GENDER 8. CATEG 31/05/2000. 2h) MAI UNRESER 9, WHETHER PERSON WITH DI ISABILITY (PWD)? 9.1 1F YES, | TYPE OF DISABILITY (OH, HH,VH, NO 10, NATIONALT ny m MARK OF VISIBLE IDENTIFICATIO ‘CITIZEN OF INDIA "A BLACKIMOLE ON THENECK i 13. MATRICULATION (l0th_ | 14, MATRICULA 12. MATRICULATION (10th CLASS) EXAMINATION BOARD CEASHROLL att Cea KERALA BOARD OF PUBLIC EXAMINATIONS 208064 2015 15, PREFERENCE OF EXAMINATION CENTERS. EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CEN’ (FIRST PREFERENCE) (SECOND PREFERENCE) (THIRD PREFERENC KOTTAYAM (9205) KOLLAM (9210) THIRUVANANTHAPURAN 16.1. WHETHER YOUARBAN EX-]16.2. DATE OF JOINING THE ARMED ]163, DATE OF DISCHARGE LIKED) SERVICEMAN (ESM) OR SERVING FORCES (DD/MMIYYYY) DISCHARGE FROM ARMED FORCE IN THE ARMED FORCES? yyYY) NO. 164, LENGTH OF SERVICE IN THE ARMED FORCES: 16:5. HAVE YOU ALREADY JOINED A CIVIL POST BY AVAILING BENEFIT (OF RESERVATION FOR EX- SERVICEMAN (ESM) ? 16.6. DATE OF JOINING TO CIVI (DDMMYYYY) 17. WHETHER SUFFERING FROM CEREBRAL PALSY ? 17,1.DO YOU HAVE A PHYSICAL LIMITATION TO WRITE AND SCRIBE IS REQUIRED TO WRITE ON YOUR (CERTIFICATE TO THIS EFFECT FROM THE CHIEF MEDICAL OFFICER/ CIVIL SURGEON & MEDICAL SUPERI ‘OF A GOVERNMENT HEALTH CARE INSTITUTION AS PER NOTICE OF THE EXAMINATION WOULD BE REQl ‘THE TIME OF EXAMINATION) ? 172 WHETHER SCRIBE IS REQUIRED ? 17.3 WILL YOU MAKE YOUR OWN ARRANGEMENT OF SCRIBE ? 17-41F SCRIBE 1S TOBE ARR: SSC, INDICATE MEDI18.1, WHETHER SEEKING AGE RELAXATION? 18.2, IF YES, AGE RELAXATION CODE NO : ip POST@AMAYINGTOR TEE MECHANICAL ENGINEERING 20 QUALIFICATION DETAILS QUALIFINGDIPLOMA DEGREE SUBJECT STREAM DIPLOMA @) MECHANICAL ENGINEE SATO UT OF status passing vear| “"aoanb/o |. NAMEOFROARD’ | oui vo |receNtAcs UNIVERSHEY TARE 7m) TAMIENADE OTTERS TE ef 21, DO YOU WANT 10 MAKE AVAILABLE YOUR PERSONAL INFORMATION FOR ACCESSING JOB OPPORT\ TERMS OF DoP&P'S 0.M NO,39020/1/2016-ESTT.(B) DATED 21.06.2016 ? ‘YES ADDRESS DETAIL 22, CORRESPONDENCE ADDRESS: 23, PERMANENT ADDRESS JAYAVIL .M CHERIYANAD CHERIYANAD 689511 TAYAVILASAM CHERIYANAD CHERIY ANAE DISTRICT: ALAPPUZHA DISTRICT-ALAPPUZHA STATE:KERALA STATE:KERALA. PIN : 689511 PIN: 689511 MOBILE NO: 8547444118 EMAIL: [email protected] 24, CONTACT FOR OTHER NATIONALS 25, WHETHER THs PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 12-MAY-2022? YES FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION ‘NOT EXEMPTED, 100 TGAOFRZIIT (02/09/202 DECLARATION 1. [HAVE READ THE NOTICE OF THE EXAMINATION AND ACCEPT ALL THE TERMS & CONDITIONS INOTICE OF THE EXAMINATION 2. 1 HEREBY DECLARE THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE. TRUE, COMPLE! CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. | UNDERSTAND THAT IN THE EVENT O} INFORMATION BEING FOUND SUPPRESSED/FALSE OR INCORRECT OR INELIGIBILITY BEING DETE IBEFORE OR AFTER THE EXAMINATION, MY.CANDIDATURE/ APPOINTMENT IS LIABLE TO BE CAN |AM WILLING TO SERVE ANYWHERE IN INDIA. $. I DECLARE THAT THE PHOTOGRAPH UPLOADED IN THE APPLICATION FORM HAS BEEN TAKEN AFTER THE STIPULATED DATED, PRINT TAKEN ON 02/09/2022 6:89:22 PM IP ADDRESS:15