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Application Form Draft Print For All

This document is an application form for the Combined Higher Secondary Level Examination 2020 by the Staff Selection Commission. It contains the personal and educational details of the applicant named Ampita Bhowmick such as name, father's name, date of birth, gender, category, education details, address and declaration. The application is provisionally accepted pending verification of details.

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Ampita Bhowmick
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© © All Rights Reserved
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48 views

Application Form Draft Print For All

This document is an application form for the Combined Higher Secondary Level Examination 2020 by the Staff Selection Commission. It contains the personal and educational details of the applicant named Ampita Bhowmick such as name, father's name, date of birth, gender, category, education details, address and declaration. The application is provisionally accepted pending verification of details.

Uploaded by

Ampita Bhowmick
Copyright
© © All Rights Reserved
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, 2020

REGISTRATION NO: 10002790595

APPLICATION IS PROVISIONALLY ACCEPTED


1. NAME AS PER 2. NEW/ CHANGED 3. FATHER'S NAME 4. MOTHER'S NAME
MATRICULATION CERTIFICATE NAME
AMPITA BHOWMICK - ALOK KUMAR BHOWMICK LIPI BHOWMICK
6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2021
05/12/1996 24 FEMALE OBC
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 NO MARK
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
CENTRAL BOARD OF SECONDARY EDUCATION
3125360 2013
(CBSE)
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTRE EXAMINATION CENTRE EXAMINATION CENTRE
(FIRST PREFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE)
GUWAHATI (DISPUR) ( 5105 ) SHILLONG ( 5401 ) JORHAT ( 5107 )
17. WHETHER 12TH STANDARD PASS IN SCIENCE STREAM WITH
16. MEDIUM FOR TYPING TEST: MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR
EQUIVALENT(FOR C&AG AS DATA ENTRY OPERATOR):
ENGLISH YES
18.WHETHER EX- 18.1. DATE OF DISCHARGE 18.2. LENGTH OF SERVICE IN THE ARMED FORCES (IN
SERVICEMAN (ESM) ? FROM ARMED FORCES YEARS)
(DD/MM/YYYY)

NO - -
18.3. HAVE YOU ALREADY JOINED A CIVIL POST BY 18.4. DATE OF JOINING THE CIVIL POST (DD/MM/YYYY)
AVAILING BENEFIT OF RESERVATION FOR EX-
SERVICEMAN (ESM) ?
- -
19.1. WHETHER SUFFERING 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) ?
-
19.3. WHETHER SCRIBE IS REQUIRED ? 19.4. WILL YOU 19.5. IF SCRIBE IS TO BE ARRANGED BY SSC, INDICATE
MAKE YOUR MEDIUM
OWN
ARRANGEMENT
OF SCRIBE ?
- - -

20. WHETHER SEEKING AGE RELAXATION ? 20.1 IF YES, AGE RELAXATION CODE

NO
-
21. HIGHEST QUALIFICATION
INTERMEDIATE/ HIGHER SECONDARY/ 10+2 (2)
22. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
12TH STANDARD
STATE/ UT OF NAME OF BOARD/
STATUS PASSING YEAR ROLL NO PERCENTAGE CGPA
BOARD/ UNIVERSITY UNIVERSITY
PASSED 2017 ASSAM OTHERS 020036163010 63 -
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. CORRESPONDENCE ADDRESS 25. PERMANENT ADDRESS
FLAT NO 602 BLOCK B GOKUL NIWAS ADABARI FLAT NO 602 BLOCK B GOKUL NIWAS ADABARI
TINIALI TINIALI
PANDU PORT ROAD GUWAHATI 12 PANDU PORT ROAD GUWAHATI 12
DISTRICT: KAMRUP DISTRICT:KAMRUP
STATE: ASSAM STATE: ASSAM
PIN : 781012 PIN : 781012
MOBILE NO: 6000967110 EMAIL: [email protected]
27. DATE ON WHICH PHOTOGRAPH HAS BEEN TAKEN 28. WHETHER THE DATE OF PHOTOGRAPH IS CLEARLY
(DD/MM/YYYY): PRINTED ON THE PHOTOGRAPH
26/08/2020 YES
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
EXEMPTED - - -
DECLARATION
1. I HAVE READ THE NOTICE OF EXAMINATION AND ACCEPT ALL THE TERMS & CONDITIONS
MENTIONED THEREIN.

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: 15/12/2020 4:07:21 AM IP ADDRESS: 47.29.160.156

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