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    Application Form Draft Print For All

    Uploaded by

    Amar Naik
    The document is an incomplete application for the Combined Graduate Level Examination, 2020. It provides personal details of the applicant such as name, father's name, date of birth, gender, category, education details, correspondence address and declaration. However, it is marked as incomplete as the fee payment details including transaction number and date are missing. The applicant is informed that submission of complete application is required to appear for the examination.

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

    Application Form Draft Print For All

    Uploaded by

    Amar Naik
    72 views3 pages
    The document is an incomplete application for the Combined Graduate Level Examination, 2020. It provides personal details of the applicant such as name, father's name, date of birth, gender, category, education details, correspondence address and declaration. However, it is marked as incomplete as the fee payment details including transaction number and date are missing. The applicant is informed that submission of complete application is required to appear for the examination.

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    © © All Rights Reserved

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    The document is an incomplete application for the Combined Graduate Level Examination, 2020. It provides personal details of the applicant such as name, father's name, date of birth, gender, category, education details, correspondence address and declaration. However, it is marked as incomplete as the fee payment details including transaction number and date are missing. The applicant is informed that submission of complete application is required to appear for the examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    72 views3 pages

    Application Form Draft Print For All

    Uploaded by

    Amar Naik
    The document is an incomplete application for the Combined Graduate Level Examination, 2020. It provides personal details of the applicant such as name, father's name, date of birth, gender, category, education details, correspondence address and declaration. However, it is marked as incomplete as the fee payment details including transaction number and date are missing. The applicant is informed that submission of complete application is required to appear for the examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    STAFF SELECTION COMMISSION

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


    110003

    COMBINED GRADUATE LEVEL EXAMINATION, 2020

    REGISTRATION NO: 50002853380

    APPLICATION IS INCOMPLETE

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


    MATRICULATION CERTIFICATE NAME

    SURAJ KUMAR NAIK - BANSHI NAIK SUSHILA


    6. AGE AS ON
    5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
    01/01/2021
    01/05/1994 26.8 MALE UNRESERVED
    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 A SCAR MARK ON LEFT HAND
    12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
    BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
    CHHATTISGARH BOARD OF SECONDARY EDUCATION 102202132 2012
    15. PREFERENCE OF EXAMINATION CENTERS
    EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
    (FIRST PRFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE )
    BILASPUR ( 6202 ) RAIPUR ( 6204 ) DURG ( 6205 )
    16.2. LENGTH OF SERVICE 16.3. DATE OF DISCHARGE FROM ARMED FORCES
    16.1. WHETHER EX-
    IN THE ARMED FORCES (IN (DD/MM/YYYY)
    SERVICEMAN (ESM) ?
    YEARS)
    NO - -
    16.4. HAVE YOU ALREADY JOINED A CIVIL POST BY
    AVAILING BENEFIT OF RESERVATION FOR EX- 16.5. DATE OF JOINING THE CIVIL POST (DD/MM/YYYY)
    SERVICEMAN (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 ARRANGED
    ARRANGEMENT OF SCRIBE ? BY SSC, INDICATE MEDIUM
    - - -
    18. ARE YOU ALSO APPLYING FOR THE POST OF JUNIOR 19. DO YOU POSSESS EQ FOR THE POST OF JUNIOR
    STATISTICAL OFFICER (MoSPI)? STATISTICAL OFFICER (MoSPI)?
    NO -
    20. WHETHER SEEKING AGE RELAXATION ? 20.1 IF YES, AGE RELAXATION CODE
    NO -
    21. HIGHEST EDUCATIONAL QUALIFICATION
    M.E. (30)
    22. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
    GRADUATION
    STATE/ UT OF
    PASSING NAME OF
    STATUS BOARD/ ROLL NO PERCENTAGE CGPA
    YEAR BOARD/ UNIVERSITY
    UNIVERSITY
    APPEARING - TAMIL NADU ANNA UNIVERSITY - - -
    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 ?
    NO
    ADDRESS DETAIL
    24. CORRESPONDENCE ADDRESS 25. PERMANENT ADDRESS
    Q NO 606 EAST NEPAL GATE CHURCHA COLLIERY Q NO 606 EAST NEPAL GATE CHURCHA COLLIERY
    DISTRICT KORIYA DISTRICT KORIYA
    DISTRICT: KOREA DISTRICT:KOREA
    STATE: CHHATTISGARH STATE: CHHATTISGARH
    PIN : 497339 PIN : 497339
    MOBILE NO: 9399731638 EMAIL: [email protected]
    27. DATE ON WHICH THE UPLOADED PHOTOGRAPH 28. WHETHER THE DATE OF PHOTOGRAPH IS CLEARLY
    HAS BEEN TAKEN PRINTED ON THE PHOTOGRAPH
    (DD/MM/YYYY):
    19/01/2021 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.
    PRINT TAKEN ON: 19/01/2021 3:43:44 PM IP ADDRESS:27.97.45.98

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