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Application Form Draft Print For All

The document is an incomplete application form for the Junior Engineer (Civil, Mechanical, Electrical and Quantity Surveying & Contracts) Examination 2019 by the Staff Selection Commission. It contains details such as the applicant's name, father's name, date of birth, gender, nationality, education details, exam center preferences, address details, and a declaration signed by the applicant. However, it is marked as incomplete as some required details such as fee payment details are missing.

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Farhan Khan
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0% found this document useful (0 votes)
79 views2 pages

Application Form Draft Print For All

The document is an incomplete application form for the Junior Engineer (Civil, Mechanical, Electrical and Quantity Surveying & Contracts) Examination 2019 by the Staff Selection Commission. It contains details such as the applicant's name, father's name, date of birth, gender, nationality, education details, exam center preferences, address details, and a declaration signed by the applicant. However, it is marked as incomplete as some required details such as fee payment details are missing.

Uploaded by

Farhan Khan
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
JUNIOR ENGINEER (CIVIL, MECHANICAL,
ELECTRICAL AND QUANTITY SURVEYING &
CONTRACTS) EXAMINATION 2019
REGISTRATION NO: 75001584355

APPLICATION IS INCOMPLETE
1. NAME AS PER 2. NEW/CHANGED 3. FATHER'S NAME 4. MOTHER'S NAME
MATRICULATION NAME
CERTIFICATE
FARHANULLAH
- ZAHIDULLAH KHAN FIROZA
ZAHIDULLAH KHAN
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01-01-2020 7. GENDER
22/02/1998 21.1 MALE
10. MARK OF VISIBLE
8. CATEGORY 9. NATIONALITY
IDENTIFICATION
UNRESERVED CITIZEN OF INDIA CUT ON CHIN
11. MATRICULATION (10th CLASS) EXAMINATION 12. MATRICULATION (10th 13. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
MAHARASHTRA STATE BOARD OF SECONDARY
J074425 2013
AND HIGHER SECONDARY EDUCATION
14. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )

NAGPUR ( 7205 ) AMRAVATI ( 7201 ) NAVI MUMBAI ( 7217 )


15.WHETHER EX- 15.1. HAVE YOU ALREADY 15.2. LENGTH OF SERVICE IN 15.3. DATE OF DISCHARGE
SERVICEMAN (ESM)? JOINED A CIVIL POST BY ARMED FORCES ( IN YEARS ) FROM ARMED FORCES
AVAILING BENEFIT OF (DD/MM/YYYY)
RESERVATION FOR EX-
SERVICEMAN (ESM) :?
NO - - -
16. WHETHER PERSON WITH DISABILITY 16.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
(PWD) ?
NO -
17. 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
17.1 WHETHER SCRIBE IS REQUIRED 17.2 WILL YOU MAKE YOUR OWN 17.3 IF SCRIBE IS TO BE
ARRANGEMENT OF SCRIBE? ARRANGED BY SSC, INDICATE
MEDIUM
NO - -
18. WHETHER SEEKING AGE RELAXATION? 18.1 IF YES,INDICATE CODE
NO -
19. POST(S) APPLYING FOR
JE- CIVIL ENGINEERING
20. QUALIFICATION DETAILS
HIGHEST TECHNICAL QUALIFICATION RELEVANT TO SUBJECT/ STREAM
THE POST OF INTEREST
BE CIVIL ENGINEERING
21. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?
YES
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. POSTAL ADDRESS 24. PERMANENT ADDRESS
H.NO. 236/F/13 ADIWASI NAGAR NEAR YOGENDRA H.NO. 236/F/13 ADIWASI NAGAR NEAR YOGENDRA
NAGAR NAGPUR NAGAR NAGPUR
DISTRICT: NAGPUR DISTRICT:NAGPUR
STATE: MAHARASHTRA STATE: MAHARASHTRA
PIN : 440013 PIN : 440013
MOBILE NO: 7038649401 EMAIL: farhankhan021998@gmail.com
SIGNATURE

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.
PRINT TAKEN ON: 04/09/2019 8:18:37 PM

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