STAFF SELECTION COMMISSION

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

COMBINED HIGHER SECONDARY (10+2) LEVEL

REGISTRATION NO: 72001201119

APPLICATION IS INCOMPLETE
1. NAME AS PER
2. NEW/CHANGED
MATRICULATION 3. FATHER'S NAME 4. MOTHER'S NAME
NAME
CERTIFICATE
VISHAL KUMAR YADAV - YOGENDRA KUMAR YADAV SUMITRA DEVI
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2019 7. GENDER
07/10/1996 22.8 MALE
9.1 .IF YES, TYPE OF
9. WHETHER PERSON WITH
8. CATEGORY DISABILITY (OH, HH,VH,
DISABILITY (PWD) ?
OTHERS)
OBC NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA A CUT MARK ON FOREHEAD
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
BIHAR SCHOOL EXAMINATION BOARD 0622 2012
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )
PATNA (3206) ALLAHABAD (3003) MUZAFFARPUR (3205)
17. WHETHER 12th STANDARD PASS IN SCIENCE STREAM WITH
16. MEDIUM OF TYPE TEST MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR
EQUIVALENT (FOR C&AG AS DATA ENTRY OPERATOR)
ENGLISH YES
18.1. HAVE YOU ALREADY
JOINED A CIVIL POST BY 18.3. DATE OF DISCHARGE
18.WHETHER EX- 18.2. LENGTH OF SERVICE IN
AVAILING BENEFIT OF FROM ARMED FORCES
SERVICEMAN (ESM)? ARMED FORCES ( IN YEARS )
RESERVATION FOR EX- (DD/MM/YYYY)
SERVICEMAN (ESM) :?
NO - - -
19.1 DO YOU SUFFER 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)?
NO
19.5 IF SCRIBE IS TO BE
19.4 WILL YOU MAKE YOUR OWN
19.3 WHETHER SCRIBE IS REQUIRED ARRANGED BY SSC, INDICATE
ARRANGEMENT OF SCRIBE?
MEDIUM
 NO - -
20. WHETHER SEEKING AGE RELAXATION? 20.1 IF YES,INDICATE CODE
NO -
21. EDUCATIONAL QUALIFICATION
B.SC. (HONS.)

22. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?

-
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. POSTAL ADDRESS 25. PERMANENT ADDRESS
VILL- AMBA, POST- JHAJHA, PS- JHAJHA VILL- AMBA, POST- JHAJHA, PS- JHAJHA
DISTRICT: JAMUI DISTRICT: JAMUI
STATE: BIHAR STATE: BIHAR
PIN: 811308 PIN: 811308
MOBILE NO : 8825322755 EMAIL ID : vk5355621@gmail.com
SIGNATURE

FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE

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: 06/03/2019 12:12:33 PM