-/ANNEXURE-I

t-t-ttt -tt-t ttttt STAFF SELECTION COMMISSION

ttt-t -tt-tt -t tt+tt-ze1z
COMBINED GRADUATE LEVEL EXAMINATION-2012
t ttt tt +tt t -ttt` ct -t t` t t-t zttft -t-t t` ttt` ttt tt ttttt-tt t t t ta -t tt tt ( ) -t t` -tt-t t t` -t -tt -t tt tt-t t-t tt rtttt t
Please read instructions in the Notice of the Examination/Annexure-II carefully. Use Blue or Black ball pen to write in the box ( ( )

1. tt +tt t-r tt -tt-t f Name of the Examination Centre 2. t-r tt f Center Code

3. --tt tt tt tt -tt-t (t ttt -t) -t t` c t -tzt-t rt-ttt t-t -t t` t -tt-t t t-t tt t t+tt -t t` -tt -tt-t t t` t-rt t tttt t tt-t t tt tt tt tt-tt ut
Candidates Full Name (in English). Write in Capital Letters exactly as in Matriculation Certificate. Leave a box blank between any two parts of the name.


4. t` t-tt tt -tt-t (t ttt t t t+tt -t t` -tt) f Fathers Name (Write in Capital Letters in English)


5. -tt-tt tt -tt-t (t ttt t t t+tt -t t` -tt) / Mothers Name (Write in Capital Letters in English)

6. t--t tt -ttt t / Date of Birth

t` -t / Day -trt -tt /Month tt /Year

7. t -tt / Gender
(t` -tt 1--tt t z-t t)
(Write 1-Female & 2- Male)
8. tc t t-tt /Nationality
(t` -tt 1-tt-tt t t z-t-t)
(Write 1-Indian & 2 - Others)
9. zt -t / Fee
(t` -tt 1-zt -t tt t t-tt-t t z- u c tt ttt t` ttt)
(Write 1-Fee paid & 2- Exemption claimed)
10. ~ttt / Category
(t` -tt a-t-tt,1 ttt,z tttt t e-tt` tt)
(Write 9-General, 1-SC, 2-ST,
6-OBC)

10.1 t tt ttt t -tt t t t` -tt r ?
Whether Ex-serviceman ?
(t` -tt s-t -tt t t t` -tt)
(Write 3- Ex-Serviceman)
10.2. t -tt t t t` -tt t t` -t For Ex-Serviceman
ttt ttt` t / Length of Service [tt /Year]
ttt t-ttt -t t` -tt` t/Date of Discharge
(t` -t/Day -trt -ttfMonth tt /year)


11. ttt ttt zttt t` t t` tt-tt t r ?
Whether PH ?
(t` -tt 1-rt t z--trt )
(Wrire 1-Yes, 2-No)
11.1 tt` rt , tt t t` t-t t
If yes, indicate code
(t` -tt -t.t` t., s-~t.t` t., z- . t` t.)
(Write 4-OH, 5-HH,7-VH )
12. ttt ttt tt -tt -t u c -ttr-t r ?
Whether seeking Age relaxation ?
(t` -tt 1-rt t z--trt ) (Write -1-Yes, 2-No)
12.1 tt` rt , tt t t` t-t t
If yes, indicate code
(t t tt tt t tt--tt tt t t` t-t t )
(Write two digit numeric code)
12.2 (01.01.2012) tt ttt
Age as on (01.01.2012)

tt f Years -trt -t / Months t` -t / Days
13 Preference for Posts:
1 2 3 4 5 6 7 8 9 10 11 12 13

14 15 16 17 18 19 20 21 22 23 24 25 26



14 Preference for States/UTs
1 2 3 4 5 6 7 8 9 10 11 12 13 14

15 16 17 18 19 20 21 22 23 24 25 26 27 28

15. ttt ttt t-tt tt r ?
(t` -tt s- rt )
Whether belong to Minority Communities
as per Govt. Orders? (Write 8, if yes.
Otherwise leave it blank)
16. tt` t` c ttt`t-t t` tt-tt t r , -tt ttt ttttt rtt` -tt` tt tt tttztt-tt r ? (t` -tt 1-rt , z--trt )
If VH, whether scribe is required ? (Write 1-yes, 2-No)
16.1. tt` rt , -ttt-t t t` t-t t ( t ttt t t`-t 1, t` r-t t t` -t z t` -tt )
If yes, indicate medium, ( Write 1- English, 2-Hindi)
17. zt t` +tt ttt-tt
Educational Qualification
tt t t` t-t t Indicate Code
1. -tt-tt Graduate
2. -tt-ttt-t Post- Graduate
3. t-t Other
t` ttt tt
Subject Code
t tt tt rtt` -tzt-t (%)
Percentage (%) of Marks




-ttt-t (t ttt -1, t` r-t -z t t-t-s)
Medium ( English-1, Hindi-2, Others-3)






18. ttt t-ttt tt t`ttt Details of work Experience / Govt. Service rendered
t tt tt -tt-t
Name of the Organisation(s)
t-tt-t
Designation
ttt tt t` ttt
Nature of the Duty(ies)
ttt tt t-tt` t / Period of Service
t /From -tt / To




19. t-tt: tt-t -tt-t tt` r-t t-t ttrt tt t t t-tt t ttt t t t+tt -t tt t` r-t -t -tt -t
tt tt-t tt -t t-t t t` -tt
Address: Write your complete Communication Address including your
Name in English Capital Letters or Hindi with Blue or Black Ball Pen.











21. --tt tt t r-tt+t (tt-t ttt c r-tt` -tt` t -t)
Signature of the Candidate in the
above Box (Only in running Hand)




















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ii-i
Name___________________________________________________
-iii Address_____________________________________________
_______________________________________________________
_________________________________________________________
________________________________________________________
i` -ii PIN:
-ii ii;i i.; Mobile No. : .........................................................

Email ID:.
20. ttctttt
+ :i -ii x s :i -ii ~iiii ii
tii ti -i iiii iii -ii i ii-i
iti i i . i :i i`i-iiii
(: -ii i i -ii i ii
:iiii`-ii i iii )
Photograph
Paste here firmly your recent
photograph
(4 c.m.X 5c.m)
(Do not staple. Do not get the
Photograph attested)
~iisi-ii i (i ii iiii ii .iii i t i )
Roll Number ( for Office use only)


















22. ttttt fDeclaration































zs. i . i. ii i`i i i`i
:iii
Space for CRF Stamp
r 100.00 ii i . i.
ii i`i iti ii . i
:i i`i-iii iii iii :i
ii iti :i it
ii i iii t
(:-ii i i )

Paste here firmly CRF
Stamp of r 100.00
denomination and get
it cancelled from the
post office where
purchased.
( Do not Staple)
i . i. i i i` i i` i-iiii
i ii iii ii i` ii
iii iii i` i t i :iii
Space for cancellation
stamp by post office
after affixing CRF
stamp
(i ) -i i ;:i iii i i` i ii ; ~ii ~iii i -i-i iti i ii t -i i it -iii -i t i` i ii` -i ;:i i` ii-i ii i ii iii;iii t ii
~iiii i ii -i i ~iii i :i:ii ii -i ~i:ii ii i i` ii iiii
I have not submitted any other application for this examination. I am aware that if I contravene this
rule, my application will be rejected summarily by the Commission.
(ii) -i i i` iii -i -i i i; iii ii iii-i i i -i. i` iii t ~ii -i i ii iii -iiii ii ii iii ii; ii t
I have read the provisions in the Notice of the examination carefully and hereby undertake to abide by
them.
(iii) -i it ii ii iii iii;iii t i` i -i ;:i -ii ii -i .ii i i i` i i` iii i` i ~iii :ii -ii, i i` ii ii iii ~iii` :i i ii -ii-iii ii
:iii iii ii -i i iii;iii t -i it ii ii iii iii;iii t i` i -i ;:i -ii ii
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational
qualifications etc., prescribed for admission to the examination. I also declare that I shall not make
more than three attempts for the post of Assistant in CSS.
(iv) -i it ii ii iii iii;iii t i` i -i i ~iiiii i-i iii iii ~iiii i;:i i ii i :i ii ~iiii i ii i` i:ii ii -ii ii -i i i :i
iti i ii iii t iii -i i i` i:ii ii i` ii` i iiiiii ii iii ii i iii iti -iiii iii t | |, ~|| ||||| |.||/ |.|| , |`|
|| -|||| -||| -| |~|| ~|| |||-.| -|,| |`||| ||| , |||| ,||| -|,| ||| , |||| ||`|||| | ||-| || -||| -|||.| -|,| ||
| ,
I also declare that I do not stand debarred by SSC/UPSC as on date and have never been convicted by
any court of law. I also declare that no criminal case is pending against me. Further declare that I have
never been dismissed or removed from Govt. Service or my service been terminated during probation.
(v) * ~iii :ii -ii -i iiti iii is :iii i ~i:i i` ii i-i iii i i` i
-i it ii iii iii;iii t i` i -i i is :iii ii i ~i:i i` ii i-i iii t i i` iii` -ii ~iiii -i s ii ii :i ii ii
:i iiiii ~iii` i i :ii ii -ii ii ii i` :i -i i` iii i` i t ,
* For Central Govt. Civilian Employee seeking age relaxation.
I declare that I am a Central Govt. Civilian Employee and completed 3 years regular service or regular
length of service stipulated in the Notice of the examination.
(vi) * ~ii i` -ii ii :i :i i i` ii ~iiii i i` i
-i it ii ii iii iii;iii t i` i -i :i :i-i ii :i :i i i` ii t i` i:i iii` -ii i .ii` iii i` iiii i i` ii i 8.9.1993 i
ii. ii. :i . ssc:z;zz;s :ii. (:i:ii i ) -i i` ii` ti ~ii ii i ~ii:ii iii :iii ii :i ii~ii -i ~iiii i .iii ii t i
i` -ii ii -iiii iii t it ii ii iii ii iiii t i` i -i iii :iii, iii` -ii i .ii` iii i` iiii i i` ii` ii :i ii iii ii i` i
ii i` :i -i i i` ii t , :ii iti -ii i i iiii ii ii-ii :i . ii i-i s -i i ii` ii ii i iii ;iii ( sii -ii i i) :i :i i i` ii
iti t -i it ii ii iii iii;iii t i` i -i -ii:i -ii ii ii i` :i -i i` iii i` i .ii-i -i ~ii i` -ii ii ii .i-iii -i-i t
*For Candidate belonging to OBC.
I declare that I belong to the community which is recognized as an other backward class by the Govt.
of India for the purpose of reservation in services as per order contained in Deptt. of Personnel and
Training Office Memorandum No.36012/22/93-Estt.(SCT) dated 8.9.1993. I also declare that I do not
belong to the person/sections (creamy layer) mentioned in column 3 of the schedule of the OM
mentioned above and modified vide Govt. of India DOPT OMs mentioned in the Notice. I further
declare that I will produce OBC Certificate in the prescribed format as stipulated in the Notice of the
examination.
(vii) i i-i i :i i` iii i i` i
-i ii iii iii;iii t i` i -i -ii ii i` iii -i i ~ii:ii i i-i i :i i` ii :i i i` ii -ii-iii ii :iii iii ii -i i iii;iii t
For Candidate belonging Ex-Serviceman
I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of
examination.
(viii) -i i ii ii iii iii;iii t i` i ;:i ~iii i -i-i -i i` i :iii i` iii -i i ~ii` iii-i iiiiii ~ii i` iii:i i ~ii:ii
:ii, -i i i :iti t -i :i-iiii;:i-iiii t i` i -ii ii :i -iti ii ii -i ii ; ii :i iii -ii ; t ; ;i i ii ~i:ii -ii; iii
-i ii ~i-ii-iii ii -iii iii -i -i i ~iii` iii;i` ii i i i i` i:i ii ii :iiii t
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.


:iii;Place: ..
D D M M Y Y
iiii;Date:

* ii` iii i ti ii it ii; i ii
* Strike off this sentence if not applicable
--ii ii i t:iii (iii i:ii t:ii` ii` -i -i )
Signature of candidate ( only in running hand)


~it:iiii`i ~iii i -i-i ii i i`ii iiiii
Unsigned application will be rejected

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