STAFF SELECTION COMMISSION

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

110003

MULTI TASKING (NON-TECHNICAL) STAFF

EXAMINATION, 2020

REGISTRATION NO: 30000735793

APPLICATION IS PROVISIONALLY ACCEPTED

1. NAME AS PER MATRICULATION 2. NEW/CHANGED
3. FATHER'S NAME 4. MOTHER'S NAME
CERTIFICATE NAME
GYAN PRAKASH TIWARI - KAMLESH KUMAR TIWARI SARITA TIWARI
6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2021
25/07/2000 20.5 MALE UNRESERVED
9. WHETHER PERSON WITH DISABILITY (PwD)? 9.1 IF YES, TYPE OF DISABILITY
NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA MOLE ON NOSE
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
BOARD OF HIGH SCHOOL AND INTERMEDIATE
1806587 2015
EDUCATION UTTAR PRADESH
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )
PRAYAGRAJ ( 3003 ) VARANASI ( 3013 ) KANPUR ( 3009 )
16.2. LENGTH OF SERVICE IN
16.1. WHETHER EX- 16.3. DATE OF DISCHARGE FROM ARMED FORCES
THE ARMED FORCES
SERVICEMAN (ESM)? (DD/MM/YYYY)
( IN YEARS )
NO - -
16.4. HAVE YOU ALREADY JOINED A CIVIL POST BY
16.5. DATE OF JOINING TO CIVIL POST
AVAILING BENEFIT OF RESERVATION FOR EX-SERVICEMAN
(DD/MM/YYYY)
(ESM) ?
- -
17.1 WHETHER SUFFERING FROM 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
ARRANGEMENT OF SCRIBE? ARRANGED BY SSC, INDICATE
MEDIUM
- - -
18. WHETHER SEEKING AGE RELAXATION? 18.1 IF YES,INDICATE CODE
NO -
19. STATE(S) / U.T.(S) PREFERENCE CODE
12,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X
20. HIGHEST EDUCATIONAL QUALIFICATION
MATRICULATION/ 10TH CLASS PASS (1)
21. DETAILS OF QUALIFYING EDUCATION
10TH STANDARD
STATUS PASSING STATE/ UT OF NAME OF BOARD/ ROLL NO PERCENTAGE CGPA
YEAR BOARD/ UNIVERSITY UNIVERSITY
PASSED 2015 UTTAR PRADESH BOARD OF HIGH 1806587 72.8 -
SCHOOL AND
INTERMEDIATE
EDUCATION UTTAR
PRADESH
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
60-C/1/121 JODHWAL TELIYARGANJ PRAYAGRAJ 60-C/1/121 JODHWAL TELIYARGANJ PRAYAGRAJ
DISTRICT: ALLAHABAD DISTRICT: ALLAHABAD
STATE: UTTAR PRADESH STATE: UTTAR PRADESH
PIN: 211004 PIN: 211004
MOBILE NO. : 9616882821 EMAIL ID: [email protected]
26. DATE ON WHICH PHOTOGRAPH HAS BEEN TAKEN 27. WHETHER THE DATE OF PHOTOGRAPH IS CLEARLY
(DD/MM/YYYY): PRINTED ON THE PHOTOGRAPH
01/03/2021 YES
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
NOT EXEMPTED 100 IGAKQMVVG3 03/03/2021
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.
PRINT TAKEN ON: 03/03/2021 8:44:01 PM IP ADDRESS: 47.15.181.139