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    Shivam Mts

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    Ankit Yadav
    Shivam Shourya has applied for the Multi Tasking (Non-Technical) Staff, and Havaldar (CBIC & CBN) Examination, 2021 conducted by the Staff Selection Commission. He was born on November 28, 2000 in Muzaffarpur, Bihar. He has passed his 10th standard examination in 2016 from Bihar School Examination Board with 51.80% marks. He has selected Muzaffarpur, Patna and Purnea as his examination center preferences. He has declared that all information provided in the application is true.

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    © All Rights Reserved
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    Shivam Mts

    Uploaded by

    Ankit Yadav
    35 views2 pages
    Shivam Shourya has applied for the Multi Tasking (Non-Technical) Staff, and Havaldar (CBIC & CBN) Examination, 2021 conducted by the Staff Selection Commission. He was born on November 28, 2000 in Muzaffarpur, Bihar. He has passed his 10th standard examination in 2016 from Bihar School Examination Board with 51.80% marks. He has selected Muzaffarpur, Patna and Purnea as his examination center preferences. He has declared that all information provided in the application is true.

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    Shivam Shourya has applied for the Multi Tasking (Non-Technical) Staff, and Havaldar (CBIC & CBN) Examination, 2021 conducted by the Staff Selection Commission. He was born on November 28, 2000 in Muzaffarpur, Bihar. He has passed his 10th standard examination in 2016 from Bihar School Examination Board with 51.80% marks. He has selected Muzaffarpur, Patna and Purnea as his examination center preferences. He has declared that all information provided in the application is true.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    35 views2 pages

    Shivam Mts

    Uploaded by

    Ankit Yadav
    Shivam Shourya has applied for the Multi Tasking (Non-Technical) Staff, and Havaldar (CBIC & CBN) Examination, 2021 conducted by the Staff Selection Commission. He was born on November 28, 2000 in Muzaffarpur, Bihar. He has passed his 10th standard examination in 2016 from Bihar School Examination Board with 51.80% marks. He has selected Muzaffarpur, Patna and Purnea as his examination center preferences. He has declared that all information provided in the application is true.

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    © All Rights Reserved
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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: 20001318253

    APPLICATION RECEIVED (CONTENTS NOT VERIFIED)


    1. NAME AS PER MATRICULATION 2. NEW/CHANGED
    3. FATHER'S NAME 4. MOTHER'S NAME
    CERTIFICATE NAME
    SHIVAM SHOURYA - SHASHI BHUSHAN PRASAD LEENA KUMARI
    6. AGE AS ON
    5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
    01/01/2022
    28/11/2000 21.1 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 CUT ON MIDDLE FINGER
    12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
    BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
    BIHAR SCHOOL EXAMINATION BOARD 1600013 2016
    15. PREFERENCE OF EXAMINATION CENTERS
    EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
    ( FIRST PREFERENCE ) ( SECOND PREFERENCE ) ( THIRD PREFERENCE )
    MUZAFFARPUR ( 3205 ) PATNA ( 3206 ) PURNEA ( 3209 )
    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
    24,34,27,31,28,26,25,23,18,32,35,29,47,45,49,50,52,72,64,63,56,55,54,58,38,39,43,44,46,48,51,30,37,22,21,20,19,17,16,15,14,13,12,1
    1,33,36,40,41,42,53,57,59,60,61,62,65,66,67,68,69,70,71
    20. HIGHEST EDUCATIONAL QUALIFICATION
    BCA (17)
    21. DETAILS OF QUALIFYING EDUCATION
    10TH STANDARD
    STATUS PASSING STATE/ UT OF NAME OF BOARD/ ROLL NO PERCENTAGE CGPA
    YEAR BOARD/ UNIVERSITY UNIVERSITY
    PASSED 2016 BIHAR BIHAR SCHOOL 1600013 51.80 -
    EXAMINATION
    BOARD
    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 ?
    YES
    ADDRESS DETAIL
    23. CORRESPONDENCE ADDRESS 24. PERMANENT ADDRESS
    S/O SHASHI BHUSHAN PRASAD WARD NO 03 SODA
    BL SAHA ROAD OPPOSITE SOUTH CITY GARDEN
    GODAM ROAD BRAHAMPURA MIT MUZAFFARPUR
    KOLKATA 700053
    BIHAR
    DISTRICT: MUZAFFARPUR DISTRICT: MUZAFFARPUR
    STATE: BIHAR STATE: BIHAR
    PIN: 842003 PIN: 842003
    MOBILE NO. : 8789480869 EMAIL ID: [email protected]
    26. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 23-DEC-2021?

    YES
    FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
    NOT EXEMPTED 100 CPABPJIJO3 26/04/2022
    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: 26/04/2022 11:43:01 AM IP ADDRESS: 116.193.135.119
    NUMBER OF ATTEMPT: 1

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