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SSC Application Form

This document contains an application for the Combined Higher Secondary (10+2) Level Examination, 2021. It provides key details about the applicant including personal information like name, date of birth, gender, category; education details like matriculation board, year of passing, percentage; preference of examination centers; and a declaration agreeing to the terms and conditions of the exam notice.

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The True Noob
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205 views2 pages

SSC Application Form

This document contains an application for the Combined Higher Secondary (10+2) Level Examination, 2021. It provides key details about the applicant including personal information like name, date of birth, gender, category; education details like matriculation board, year of passing, percentage; preference of examination centers; and a declaration agreeing to the terms and conditions of the exam notice.

Uploaded by

The True Noob
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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 HIGHER SECONDARY (10+2) LEVEL


EXAMINATION, 2021

REGISTRATION NO: 30004599801

APPLICATION IS PROVISIONALLY ACCEPTED


1. NAME AS PER 2. NEW/ CHANGED 3. FATHER'S NAME 4. MOTHER'S NAME
MATRICULATION CERTIFICATE NAME
MUHURT ANAND - ANAND KUMAR GUPTA RESHMI
6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2022
18/04/2001 20.8 MALE OBC
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 BURN MARK IN RIGHT HAND
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
COUNCIL FOR THE INDIAN SCHOOL CERTIFICATE
6493540 2017
EXAMINATIONS (ICSE)
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTRE EXAMINATION CENTRE EXAMINATION CENTRE
(FIRST PREFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE)
LUCKNOW ( 3010 ) KANPUR ( 3009 ) PATNA ( 3206 )
17. WHETHER 12TH STANDARD PASS IN SCIENCE STREAM WITH
16. MEDIUM FOR TYPING TEST: MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR
EQUIVALENT(FOR C&AG AS DATA ENTRY OPERATOR):
ENGLISH NO
18.1. WHETHER YOU ARE AN EX- 18.2. DATE OF JOINING THE ARMED 18.3.DATE OF DISCHARGE/ LIKELY
SERVICEMAN (ESM) OR SERVING IN FORCES (DD/MM/YYYY) DATE OF DISCHARGE FROM ARMED
THE ARMED FORCES? FORCES (DD/MM/ YYYY)

NO - -
18.4. LENGTH OF SERVICE IN THE 18.5. HAVE YOU ALREADY JOINED A 18.6. DATE OF JOINING TO CIVIL POST
ARMED FORCES CIVIL POST BY AVAILING BENEFIT (DD/MM/YYYY)
OF RESERVATION FOR EX-
SERVICEMAN (ESM) ?
- - -
19.1. WHETHER SUFFERING FROM CEREBRAL-PALSY ?
-
19.2. 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) ?
-
19.3. WHETHER SCRIBE IS REQUIRED 19.4. WILL YOU MAKE YOUR OWN 19.5. IF SCRIBE IS TO BE ARRANGED
? ARRANGEMENT OF SCRIBE ? BY SSC, INDICATE MEDIUM
- - -

20.1. WHETHER SEEKING AGE RELAXATION ? 20.2. IF YES, AGE RELAXATION CODE

NO
-
21. HIGHEST EDUCATIONAL QUALIFICATION
INTERMEDIATE/ HIGHER SECONDARY/ 10+2 (2)
22. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
EQUIVALENT TO 12TH STANDARD
STATE/ UT OF NAME OF BOARD/
STATUS PASSING YEAR ROLL NO PERCENTAGE CGPA
BOARD/ UNIVERSITY UNIVERSITY
PASSED 2019 UTTAR PRADESH OTHERS 6493540 77 -
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 ?
YES
ADDRESS DETAIL
24. CORRESPONDENCE ADDRESS 25. PERMANENT ADDRESS
ES-2/698 SECTOR-F ES-2/698 SECTOR-F
JANKIPURAM JANKIPURAM
DISTRICT: LUCKNOW DISTRICT:LUCKNOW
STATE: UTTAR PRADESH STATE: UTTAR PRADESH
PIN : 226021 PIN : 226021
MOBILE NO: 8922015735 EMAIL: [email protected]
27. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 01-NOV-2021?
YES
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
NOT EXEMPTED 100 CPABKOAXB3 16/02/2022
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: 16/02/2022 2:23:02 PM IP ADDRESS: 106.208.150.22

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