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    CHSL 0203

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    Kushagra Gautam
    The document is an incomplete application form for the Combined Higher Secondary (10+2) Level Examination, 2022 conducted by the Staff Selection Commission. It contains details such as the applicant's name, father's name, date of birth, gender, category, education details, address and declaration. However, it is marked as incomplete as the fee payment details and photograph upload date are missing.

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

    CHSL 0203

    Uploaded by

    Kushagra Gautam
    13 views3 pages
    The document is an incomplete application form for the Combined Higher Secondary (10+2) Level Examination, 2022 conducted by the Staff Selection Commission. It contains details such as the applicant's name, father's name, date of birth, gender, category, education details, address and declaration. However, it is marked as incomplete as the fee payment details and photograph upload date are missing.

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    chsl0203

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    The document is an incomplete application form for the Combined Higher Secondary (10+2) Level Examination, 2022 conducted by the Staff Selection Commission. It contains details such as the applicant's name, father's name, date of birth, gender, category, education details, address and declaration. However, it is marked as incomplete as the fee payment details and photograph upload date are missing.

    Copyright:

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

    CHSL 0203

    Uploaded by

    Kushagra Gautam
    The document is an incomplete application form for the Combined Higher Secondary (10+2) Level Examination, 2022 conducted by the Staff Selection Commission. It contains details such as the applicant's name, father's name, date of birth, gender, category, education details, address and declaration. However, it is marked as incomplete as the fee payment details and photograph upload date are missing.

    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 HIGHER SECONDARY (10+2) LEVEL
    EXAMINATION, 2022

    REGISTRATION NO: 83000365170

    APPLICATION IS INCOMPLETE

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


    KUSHAGRA GAUTAM - SUNIL BABITA
    5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/01/2022 7. GENDER 8. CATEGORY
    11/10/1998 23.2 MALE EWS
    9. WHETHER PERSON WITH DISABILITY (PwBD) ? 9.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)

    NO -

    10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION


    CITIZEN OF INDIA MOLE ON LEFT SIDE OF LIP
    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) 5233513 2012
    15. PREFERENCE OF EXAMINATION CENTERS
    EXAMINATION CENTRE EXAMINATION CENTRE EXAMINATION CENTRE
    (FIRST PREFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE)
    ROORKEE ( 2006 ) HARIDWAR ( 2005 ) DELHI ( 2201 )
    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 YES
    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 OF (DD/MM/YYYY)
    RESERVATION FOR EX-SERVICEMAN
    (ESM) ?
    - - -
    19.1.ARE YOU A PERSON WITH BENCHMARK DISABILITIES (i.e. 40% OR MORE) IN THE CATEGORY OF BLINDNESS,
    BOTH ARMS AFFECTED- BA AND/ OR 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
    B. TECH (14)
    22. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
    12TH STANDARD
    STATE/ UT OF NAME OF BOARD/
    STATUS PASSING YEAR ROLL NO PERCENTAGE CGPA
    BOARD/ UNIVERSITY UNIVERSITY
    CENTRAL BOARD
    OF SECONDARY
    PASSED 2015 DELHI 5903158 48 -
    EDUCATION
    (CBSE)
    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
    HOUSE NUMBER 373 SHAHBUDINPUR MUZAFFARNAGAR HOUSE NUMBER 373 SHAHBUDINPUR MUZAFFARNAGAR
    UTTAR PRADESH UTTAR PRADESH
    DISTRICT: MUZAFFAR NAGAR DISTRICT:MUZAFFAR NAGAR
    STATE: UTTAR PRADESH STATE: UTTAR PRADESH
    PIN : 251001 PIN : 251001
    MOBILE NO: 9870696547 EMAIL: [email protected]
    27. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 06-SEPTEMBER-2022?
    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.

    3. I DECLARE THAT THE PHOTOGRAPH UPLOADED IN THE APPLICATION FORM HAS BEEN TAKEN ON OR
    AFTER THE STIPULATED DATED.

    4. I AGREE TO AUTHORIZE SSC TO USE MY AADHAR DATA FOR VERIFICATION PURPOSE.


    PRINT TAKEN ON: 29/12/2022 10:50:46 PM IP ADDRESS: 223.233.78.31

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