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Applicationform Draft Print For All

Uploaded by

7235893k
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 GRADUATE LEVEL EXAMINATION, 2022

REGISTRATION NO: 30002389901

APPLICATION IS INCOMPLETE

1. NAME AS PER 2. NEW/ CHANGED 3. FATHER'S NAME 4. MOTHER'S NAME


MATRICULATION CERTIFICATE NAME
SHIVAM KUMAR SHUKLA - PRAMOD KUMAR SHUKLA CHHAYA SHUKLA
6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2022
08/12/2001 20 MALE EWS
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 MOLE ON LEFTSIDE NOSE
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) 5630283 2016
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
(FIRST PRFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE )
PRAYAGRAJ ( 3003 ) LUCKNOW ( 3010 ) GORAKHPUR ( 3007 )
16.2. DATE OF JOINING THE ARMED FORCES 16.3. DATE OF DISCHARGE/ LIKELY
16.1. WHETHER YOU ARE AN EX-
(DD/MM/YYYY) DATE OF DISCHARGE FROM ARMED
SERVICEMAN (ESM) OR SERVING
FORCES (DD/MM/ YYYY)
IN THE ARMED FORCES?

NO - -
16.5. HAVE YOU ALREADY JOINED A CIVIL
16.4. LENGTH OF SERVICE IN THE 16.5. DATE OF JOINING TO CIVIL POST
POST BY AVAILING BENEFIT OF
ARMED FORCES (DD/MM/YYYY)
RESERVATION FOR EX-SERVICEMAN (ESM) ?
- - -
17. 1. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (i.e. MORE THAN 40%) IN THE CATEGORY OF BLINDNESS,
LOCOMOTOR DISABILITY (BOTH ARMS AFFECTED- BA) AND CEREBRAL PALSY ?
-

17.2. 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) ?
-
17.3. WHETHER SCRIBE IS REQUIRED ? 17.4. WILL YOU MAKE YOUR OWN 17.5. IF SCRIBE IS TO BE ARRANGED BY
ARRANGEMENT OF SCRIBE ? SSC, INDICATE MEDIUM
- - -
18.1. ARE YOU ALSO APPLYING FOR THE POST OF JUNIOR 18.2. DO YOU POSSESS EQ FOR THE POST OF JUNIOR
STATISTICAL OFFICER (MoSPI)? STATISTICAL OFFICER (MoSPI)?
NO -
19.1. WHETHER SEEKING AGE RELAXATION ? 19.2. IF YES, AGE RELAXATION CODE
NO -
20. HIGHEST EDUCATIONAL QUALIFICATION
B.SC. (9)
21. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
GRADUATION
STATE/ UT OF
NAME OF
STATUS PASSING YEAR BOARD/ ROLL NO PERCENTAGE CGPA
BOARD/ UNIVERSITY
UNIVERSITY
PASSED 2021 UTTAR PRADESH OTHERS 21801120310659 54.2 -
22. 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
23. CORRESPONDENCE ADDRESS 24. PERMANENT ADDRESS
NAI BASTI BAIRAGI PURWA NAI BAZAR NAI BASTI BAIRAGI PURWA NAI BAZAR
TULSIPUR TULSIPUR
DISTRICT: BALRAMPUR DISTRICT:BALRAMPUR
STATE: UTTAR PRADESH STATE: UTTAR PRADESH
PIN : 271208 PIN : 271208
MOBILE NO: 7235893201 EMAIL: [email protected]
26. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 17-JUNE-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 AADHAR DATA FOR VERIFICATION PURPOSE.


PRINT TAKEN ON: 13/10/2022 2:39:48 AM IP ADDRESS:171.76.244.157

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