STAFF SELECTION COMMISSION

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

110003
JUNIOR ENGINEER (CIVIL, MECHANICAL,
ELECTRICAL AND QUANTITY SURVEYING &
CONTRACTS) EXAMINATION, 2023
REGISTRATION NO: 82000221636

APPLICATION IS INCOMPLETE

1. NAME AS PER MATRICULATION 2. NEW/ CHANGED

3. FATHER'S NAME 4. MOTHER'S NAME
CERTIFICATE NAME
KUMAR GAURAV - JITENDRA PRASAD SINGH MINA DEVI
6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2022
10/02/1997 26.5 MALE UNRESERVED
9. WHETHER PERSON WITH DISABILITY (PWD) ? 9.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA A CUT MARK ON RIGHT SIDE OF FOREHEAD
13. MATRICULATION (10th 14. MATRICULATION (10th
12. MATRICULATION (10th CLASS) EXAMINATION BOARD
CLASS) ROLL NO CLASS) YEAR OF PASSING
CENTRAL BOARD OF SECONDARY EDUCATION (CBSE) 7136568 2012
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
(FIRST PREFERENCE) (SECOND PREFERENCE) (THIRD PREFERENCE)
PATNA ( 3206 ) MUZAFFARPUR ( 3205 ) VARANASI ( 3013 )
16.1. WHETHER YOU ARE AN EX- 16.2. DATE OF JOINING THE ARMED 16.3. DATE OF DISCHARGE/ LIKELY DATE OF
SERVICEMAN (ESM) OR SERVING FORCES (DD/MM/YYYY) DISCHARGE FROM ARMED FORCES (DD/MM/
IN THE ARMED FORCES? YYYY)
NO - -
16.5. HAVE YOU ALREADY JOINED A
16.4. LENGTH OF SERVICE IN THE CIVIL POST BY AVAILING BENEFIT 16.6. DATE OF JOINING TO CIVIL POST
ARMED FORCES OF RESERVATION FOR EX- (DD/MM/YYYY)
SERVICEMAN (ESM) ?
- - -
17. WHETHER SUFFERING FROM CEREBRAL PALSY ?
-
17. 1 ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF BLINDNESS (VH)?

17.2 ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF OHBOTH ARMS AFFECTED
(OH-BA) OR OI-I- CEREBRAL PALSY (OH-CP)?

17.3 DO YOU HAVE A PHYSICAL LIMITATION TO WRITE AS PER PARA 9.2 OR 9.3 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.)?
17.4 WHETHER SCRIBE IS REQUIRED ? 17.5 WILL YOU MAKE YOUR OWN 17.6 IF SCRIBE IS TO BE ARRANGED BY
ARRANGEMENT OF SCRIBE ? SSC, INDICATE MEDIUM
- - -

18.1. WHETHER SEEKING AGE RELAXATION ? 18.2. IF YES, AGE RELAXATION CODE
NO -
19. POST(S) APPLYING FOR
JE- CIVIL ENGINEERING
20. QUALIFICATION DETAILS
EXP(MIN. 2
QUALIFYING DIPLOMA/ DEGREE SUBJECT/ STREAM
YEARS)
DIPLOMA (4) CIVIL ENGINEERING 3
STATE/ UT OF
PASSING NAME OF BOARD/ PERCENTA
STATUS BOARD/ ROLL NO CGPA
YEAR UNIVERSITY GE
UNIVERSITY
NOIDA
UTTAR BT/CE/1502/00
PASSED 2019 INTERNATIONAL 61 -
PRADESH 6
UNIVERSITY
20.1 HIGHEST EDUCATIONAL QUALIFICATION
B.TECH
21. 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
22. CORRESPONDENCE ADDRESS 23. PERMANENT ADDRESS
VILL - BAHIRO ARA VILL - BAHIRO ARA
DISTRICT: BHOJPUR DISTRICT:BHOJPUR
STATE: BIHAR STATE: BIHAR
PIN : 802301 PIN : 802301
MOBILE NO: 8298613444 EMAIL: [email protected]
24. CONTACT FOR OTHER NATIONALS

25. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 12-MAY-2022?

YES
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
NOT EXEMPTED 100 - -
 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 AADHAAR DATA FOR VERIFICATION PURPOSE.

PRINT TAKEN ON: 01/08/2023 10:43:53 PM IP ADDRESS:152.58.189.137

NUMBER OF ATTEMPT: 1