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    Application Form Draft Print For All

    Uploaded by

    Bibrata Ghosh

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Application Form Draft Print For All

    Uploaded by

    Bibrata Ghosh
    3 views2 pages

    Original Title

    ApplicationFormDraftPrintForAll (1) (1)

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    3 views2 pages

    Application Form Draft Print For All

    Uploaded by

    Bibrata Ghosh

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    STAFF SELECTION COMMISSION

    BLOCK NO. 12, CGO COMPLEX, LODHI ROAD,


    NEW DELHI 110003

    MULTI TASKING (NON-TECHNICAL) STAFF, AND


    HAVALDAR (CBIC & CBN) EXAMINATION, 2021

    REGISTRATION NO: 40000772443

    APPLICATION RECEIVED (CONTENTS NOT VERIFIED)


    1. NAME AS PER MATRICULATION 2. NEW/CHANGED
    3. FATHER'S NAME 4. MOTHER'S NAME
    CERTIFICATE NAME
    BIBRATA GHOSH - BISWANATH GHOSH KAVITA GHOSH
    6. AGE AS ON
    5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
    01/01/2022
    05/02/1998 23.1 MALE OBC
    9. WHETHER PERSON WITH DISABILITY (PwD)? 9.1 IF YES, TYPE OF DISABILITY
    NO -
    10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
    CITIZEN OF INDIA ONE MOLE IN MY LEFT HAND
    12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
    BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
    WEST BENGAL BOARD OF SECONDARY EDUCATION 105161B-0098 2013
    15. PREFERENCE OF EXAMINATION CENTERS
    EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
    ( FIRST PREFERENCE ) ( SECOND PREFERENCE ) ( THIRD PREFERENCE )
    KOLKATA ( 4410 ) KALYANI ( 4419 ) BHUBANESHWAR ( 4604 )
    16.1. WHETHER YOU ARE AN EX- 16.3.DATE OF DISCHARGE/ LIKELY
    16.2. DATE OF JOINING THE ARMED
    SERVICEMAN (ESM) OR SERVING DATE OF DISCHARGE FROM ARMED
    FORCES (DD/MM/YYYY)
    IN THE ARMED FORCES? FORCES (DD/MM/ YYYY)
    NO - -
    16.5. HAVE YOU ALREADY JOINED A
    16.4. LENGTH OF SERVICE IN THE CIVIL POST BY AVAILING BENEFIT OF 16.6. DATE OF JOINING TO CIVIL POST
    ARMED FORCES 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
    - - -
    18.1. WHETHER SEEKING AGE RELAXATION? 18.2. IF YES,INDICATE CODE
    NO -
    19. STATE(S) / U.T.(S) / CCA(S) PREFERENCE CODE
    19. STATE(S) / U.T.(S) / CCA(S) PREFERENCE CODE
    27,29,34,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,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
    INTERMEDIATE/ HIGHER SECONDARY/ 10+2 (2)
    21. DETAILS OF QUALIFYING EDUCATION
    10TH STANDARD
    STATUS PASSING STATE/ UT OF NAME OF BOARD/ ROLL NO PERCENTAGE CGPA
    YEAR BOARD/ UNIVERSITY UNIVERSITY
    PASSED 2013 WEST BENGAL WEST BENGAL 105161B-0098 75.42 -
    BOARD OF
    SECONDARY
    EDUCATION
    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 ?
    NO
    ADDRESS DETAIL
    23. CORRESPONDENCE ADDRESS 24. PERMANENT ADDRESS
    SHYAMNAGAR NORTH HANSIA SHYAMNAGAR NORTH HANSIA
    DISTRICT: NORTH 24 PARGANAS DISTRICT: NORTH 24 PARGANAS
    STATE: WEST BENGAL STATE: WEST BENGAL
    PIN: 743127 PIN: 743127
    MOBILE NO. : 7003434243 EMAIL ID: bibratabitu@gmail.com
    26. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 23-DEC-2021?

    YES
    FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
    NOT EXEMPTED 100 CPABPNSNH1 27/04/2022
    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.
    PRINT TAKEN ON: 27/04/2022 6:28:53 PM IP ADDRESS: 157.40.119.178
    NUMBER OF ATTEMPT: 1

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