STAFF SELECTION COMMISSION

BLOCK NO. 12, CGO COMPLEX, LODHI ROAD,

NEW DELHI 110003
MULTI TASKING (NON-TECHNICAL) STAFF, AND
HAVALDAR (CBIC & CBN) EXAMINATION, 2023
REGISTRATION NO: 50007229005
APPLICATION RECEIVED (CONTENTS NOT VERIFIED)
1. NAME AS PER MATRICULATION 2. NEW/CHANGED
CERTIFICATE 3. FATHER'S NAME 4. MOTHER'S NAME
NAME
SAIYAD TOSIFALI HAIDARALI - SAIYAD HAIDARALI HASINABANU
6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/08/2023
23/12/1998 24.7 MALE UNRESERVED
9. WHETHER PERSON WITH DISABILITY (PwD)? 9.1 IF YES, TYPE OF DISABILITY
NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA NONE
13. MATRICULATION (10th 14. MATRICULATION (10th
12. MATRICULATION (10th CLASS) EXAMINATION BOARD
CLASS) ROLL NO CLASS) YEAR OF PASSING
GUJARAT SECONDARY AND HIGHER SECONDARY
A1048204 2015
EDUCATION BOARD
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
( FIRST PREFERENCE ) ( SECOND PREFERENCE ) ( THIRD PREFERENCE )
AHMEDABAD ( 7001 ) GANDHINAGAR ( 7012 ) ANAND ( 7011 )

16. MEDIUM FOR COMPUTER BASED EXAMINATION(CBE)

GUJARATI (7)
17.1. WHETHER YOU ARE AN EX- 17.3.DATE OF DISCHARGE/ LIKELY DATE
17.2. DATE OF JOINING THE ARMED
SERVICEMAN (ESM) OR SERVING OF DISCHARGE FROM ARMED FORCES
FORCES (DD/MM/YYYY)
IN THE ARMED FORCES? (DD/MM/ YYYY)
NO - -
17.5. HAVE YOU ALREADY JOINED A
17.4. LENGTH OF SERVICE IN THE CIVIL POST BY AVAILING BENEFIT OF 17.6. DATE OF JOINING TO CIVIL POST
ARMED FORCES RESERVATION FOR EX-SERVICEMAN (DD/MM/YYYY)
(ESM) ?
- - -
 18.1. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF BLINDNESS (VH)?:
-
18.2. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF OH- BOTH ARMS
AFFECTED (OH-BA) OR OH- CEREBRAL PALSY (OH-CP)?:
-
18.3. Do you have a physical limitation to write as per Para 8.2 or 8.3 of the Notice (Certificate to this effect from competent authority as
per format at Annexure-I/ Annexure-IA to the Notice of Examination, would be required at the time of Examination.)? :
NO
18.4 WHETHER SCRIBE IS REQUIRED 18.5 WILL YOU MAKE YOUR OWN 18.6 IF SCRIBE IS TO BE
ARRANGEMENT OF SCRIBE? ARRANGED BY SSC, INDICATE
MEDIUM
- - -
19.1. WHETHER SEEKING AGE RELAXATION? 19.2. IF YES,INDICATE CODE
NO -
20. STATE(S) / U.T.(S) / CCA(S) PREFERENCE CODE
55,50,47,56,54,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,
X,X,X,X,X,X
21. HIGHEST EDUCATIONAL QUALIFICATION
MATRICULATION/ 10TH CLASS PASS(1)
22. DETAILS OF QUALIFYING EDUCATION
10TH STANDARD
STATUS PASSING STATE/ UT OF BOARD/ NAME OF BOARD/ ROLL NO PERCENTAGE CGPA
YEAR UNIVERSITY UNIVERSITY
PASSED 2015 GUJARAT GUJARAT A1048204 56.16 -
SECONDARY AND
HIGHER SECONDARY
EDUCATION BOARD
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
G-280 NEW FAISAL NAGAR BERAL MARKET AHMEDABAD G-280 NEW FAISAL NAGAR BERAL MARKET AHMEDABAD
CITY AHMEDABAD GUJARAT CITY AHMEDABAD GUJARAT
DISTRICT: AHMEDABAD DISTRICT: AHMEDABAD
STATE: GUJARAT STATE: GUJARAT
PIN: 380028 PIN: 380028
MOBILE NO. : 9574718048 EMAIL ID: alitosif992@gmail.com
26. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 21-APR-2023?

YES
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
NOT EXEMPTED 100 CPACXDMZY7 12/07/2023
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: 14/07/2023 8:34:59 AM IP ADDRESS: 42.106.16.130
NUMBER OF ATTEMPT: 1