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The document is an application form for the Combined Higher Secondary Level Examination 2023 submitted by Prince Kumar Bharti. It contains his personal details like name, father's name, date of birth, category, address, education qualifications. It also includes his preferences for examination centers, medium for computer based and typing tests and declaration of accepting terms and conditions of the examination notice.

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Aman Kumar
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22 views

Applicationform Draft Print For All

The document is an application form for the Combined Higher Secondary Level Examination 2023 submitted by Prince Kumar Bharti. It contains his personal details like name, father's name, date of birth, category, address, education qualifications. It also includes his preferences for examination centers, medium for computer based and typing tests and declaration of accepting terms and conditions of the examination notice.

Uploaded by

Aman Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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, 2023

REGISTRATION NO: 30004707976

APPLICATION RECEIVED (CONTENTS NOT VERIFIED)

1. NAME AS PER 2. NEW/ CHANGED


NAME 3. FATHER'S NAME 4. MOTHER'S NAME
MATRICULATION CERTIFICATE
PRINCE KUMAR BHARTI - AMARNATH SUNITA DEVI
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2023 7. GENDER 8. CATEGORY
10/08/2003 19.11 MALE SC
9. WHETHER PERSON WITH BENCHMARK DISABILITY
9.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
(PwBD) ?
NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA A CUT MARK ON THE BODY
13. MATRICULATION (10th 14. MATRICULATION (10th
12. MATRICULATION (10th CLASS) EXAMINATION BOARD
CLASS) ROLL NO CLASS) YEAR OF PASSING
BOARD OF HIGH SCHOOL AND INTERMEDIATE
2215962 2019
EDUCATION UTTAR PRADESH
15. PREFERENCE OF EXAMINATION CENTRES
EXAMINATION CENTRE EXAMINATION CENTRE EXAMINATION CENTRE
(FIRST PREFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE)
VARANASI ( 3013 ) PRAYAGRAJ ( 3003 ) GORAKHPUR ( 3007 )
16. MEDIUM FOR COMPUTER BASED EXAMINATION(CBE):
ENGLISH
18. WHETHER 12TH STANDARD PASS IN SCIENCE STREAM WITH
MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR EQUIVALENT
17. MEDIUM FOR TYPING TEST:
(FOR DEOs IN DEPARTMENT/ MINSTRY MENTIONED AT PARA 8.1 OF THE
NOTICE):
ENGLISH NO
19.1. WHETHER YOU ARE AN EX- 19.2. DATE OF JOINING THE ARMED 19.3.DATE OF DISCHARGE/ LIKELY
SERVICEMAN (ESM) OR SERVING IN FORCES (DD/MM/YYYY) DATE OF DISCHARGE FROM ARMED
THE ARMED FORCES? FORCES (DD/MM/ YYYY)

NO - -
19.4. LENGTH OF SERVICE IN THE 19.5. HAVE YOU ALREADY JOINED A 19.6. DATE OF JOINING TO CIVIL POST
ARMED FORCES CIVIL POST BY AVAILING BENEFIT OF (DD/MM/YYYY)
RESERVATION FOR EX-SERVICEMAN
(ESM) ?
- - -
20. 1. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF BLINDNESS (VH)?
-
20.2. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF OH-BOTH ARMS
AFFECTED (OH-BA) OR OH- CEREBRAL PALSY (OH-CP)?
-
20.3. DO YOU HAVE A PHYSICAL LIMITATION TO WRITE AS PER PARA 7.2 OR PARA 7.3 OF THE NOTICE (CERTIFICATE
TO THIS EFFECT FROM COMPETENT AUTHORITY AS PER FORMAT AT ANNEXURE-I/ANNEXURE-IA TO THE NOTICE OF
EXAMINATION, WOULD BE REQUIRED AT THE TIME OF EXAMINATION)?
NO
20.4. WHETHER SCRIBE IS REQUIRED ? 20.5. WILL YOU MAKE YOUR OWN 20.6. IF SCRIBE IS TO BE ARRANGED
ARRANGEMENT OF SCRIBE ? BY SSC, INDICATE MEDIUM
- - -

21.1. WHETHER SEEKING AGE RELAXATION ? 21.2. IF YES, AGE RELAXATION CODE

NO
-
22. HIGHEST EDUCATIONAL QUALIFICATION
INTERMEDIATE/ HIGHER SECONDARY/ 10+2 (2)
23. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
12TH STANDARD
STATE/ UT OF NAME OF BOARD/
STATUS PASSING YEAR ROLL NO PERCENTAGE CGPA
BOARD/ UNIVERSITY UNIVERSITY
BOARD OF HIGH
SCHOOL AND
PASSED 2021 UTTAR PRADESH INTERMEDIATE 216782804 69.60 -
EDUCATION
UTTAR PRADESH
24. 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 ?
NO
ADDRESS DETAIL
25. CORRESPONDENCE ADDRESS 26.PERMANENT ADDRESS
VILL AND POST RAMPUR VILL AND POST RAMPUR

DISTRICT: BALLIA DISTRICT:BALLIA


STATE: UTTAR PRADESH STATE: UTTAR PRADESH
PIN : 221712 PIN : 221712
MOBILE NO: 9115373781 EMAIL: [email protected]
28. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 09-FEBRUARY-2023?
YES
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.

3. I DECLARE THAT THE PHOTOGRAPH UPLOADED IN THE APPLICATION FORM HAS BEEN TAKEN ON OR
AFTER THE STIPULATED DATED.

4. I AGREE TO AUTHORIZE SSC TO USE MY AADHAR DATA FOR VERIFICATION PURPOSE.


PRINT TAKEN ON: 30/05/2023 8:42:04 PM IP ADDRESS: 47.15.2.213

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