STAFF SELECTION COMMISSION

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

110003

COMBINED GRADUATE LEVEL EXAMINATION, 2021

REGISTRATION NO: 20000854245

APPLICATION IS PROVISIONALLY ACCEPTED

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

MATRICULATION CERTIFICATE NAME

NISHCHAY KUMAR RAI - UPENDRA RAI MEENA DEVI

6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2022
21/02/1998 23.1 MALE EWS
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 BIG MOLE ON LEFT SIDE NECK

13. MATRICULATION (10th 14. MATRICULATION (10th

12. MATRICULATION (10th CLASS) EXAMINATION BOARD
CLASS) ROLL NO CLASS) YEAR OF PASSING

CENTRAL BOARD OF SECONDARY EDUCATION (CBSE) 7116724 2013

15. PREFERENCE OF EXAMINATION CENTERS

EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
(FIRST PRFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE )
MUZAFFARPUR ( 3205 ) PATNA ( 3206 ) VARANASI ( 3013 )
16.2. DATE OF JOINING THE ARMED FORCES 16.3. DATE OF DISCHARGE/ LIKELY
16.1. WHETHER YOU ARE AN EX-
(DD/MM/YYYY) DATE OF DISCHARGE FROM ARMED
SERVICEMAN (ESM) OR SERVING
FORCES (DD/MM/ YYYY)
IN THE ARMED FORCES?

NO - -
16.5. HAVE YOU ALREADY JOINED A CIVIL
16.4. LENGTH OF SERVICE IN THE 16.5. DATE OF JOINING TO CIVIL POST
POST BY AVAILING BENEFIT OF
ARMED FORCES (DD/MM/YYYY)
RESERVATION FOR EX-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 BY
ARRANGEMENT OF SCRIBE ? SSC, INDICATE MEDIUM
- - -
18.1. ARE YOU ALSO APPLYING FOR THE POST OF JUNIOR 18.2. DO YOU POSSESS EQ FOR THE POST OF JUNIOR
STATISTICAL OFFICER (MoSPI)? STATISTICAL OFFICER (MoSPI)?
NO -
19.1. ARE YOU ALSO APPLYING FOR THE POST OF 19.2. DO YOU POSSESS EQ FOR THE POST OF STATISTICAL
STATISTICAL INVESTIGATOR GRADE II (RGI)? INVESTIGATOR GRADE II (RGI)?
NO -
20.1. WHETHER SEEKING AGE RELAXATION ? 20.2. IF YES, AGE RELAXATION CODE
NO -
21. HIGHEST EDUCATIONAL QUALIFICATION
B. TECH (14)
22. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
GRADUATION
STATE/ UT OF
NAME OF
STATUS PASSING YEAR BOARD/ ROLL NO PERCENTAGE CGPA
BOARD/ UNIVERSITY
UNIVERSITY
INDIAN MARITIME
PASSED 2020 TAMIL NADU 1631608042 71.95 -
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 ?
YES
ADDRESS DETAIL
24. CORRESPONDENCE ADDRESS 25. PERMANENT ADDRESS
VILLAGE DUBAHA POST DUBAHA ADAPUR EAST VILLAGE DUBAHA POST DUBAHA ADAPUR EAST
CHAMPARAN BIHAR CHAMPARAN BIHAR
DISTRICT: EAST CHAMPARAN DISTRICT:EAST CHAMPARAN
STATE: BIHAR STATE: BIHAR
PIN : 845301 PIN : 845301
MOBILE NO: 7306667069 EMAIL: [email protected]
27. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 24-SEP-2021?
YES
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
NOT EXEMPTED 100 CPABGYBML4 27/12/2021
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.

3. I DECLARE THAT THE PHOTOGRAPH UPLOADED IN THE APPLICATION FORM HAS BEEN TAKEN ON OR AFTER
THE STIPULATED DATED.
PRINT TAKEN ON: 27/12/2021 3:33:48 PM IP ADDRESS:157.35.56.70