STAFF SELECTION COMMISSION

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

110003

COMBINED GRADUATE LEVEL EXAMINATION, 2020

REGISTRATION NO: 20000851327

APPLICATION IS INCOMPLETE

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

MATRICULATION CERTIFICATE NAME

BHANU PRAKASH - PRAKASH THAKUR SUSHMA THAKUR

6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2021
01/11/1992 28.2 MALE UNRESERVED
9. WHETHER PERSON WITH DISABILITY (PWD) ? 9.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA A MOLE IN LEFT EYE BROW
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
COUNCIL FOR THE INDIAN SCHOOL CERTIFICATE
T/4731/022 2008
EXAMINATIONS (ICSE)
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER EXAMINATION CENTER EXAMINATION CENTER
(FIRST PRFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE )
DELHI ( 2201 ) DEHRADUN ( 2002 ) HARIDWAR ( 2005 )
16.2. LENGTH OF SERVICE 16.3. DATE OF DISCHARGE FROM ARMED FORCES
16.1. WHETHER EX-
IN THE ARMED FORCES (IN (DD/MM/YYYY)
SERVICEMAN (ESM) ?
YEARS)
NO - -
16.4. HAVE YOU ALREADY JOINED A CIVIL POST BY
AVAILING BENEFIT OF RESERVATION FOR EX- 16.5. DATE OF JOINING THE CIVIL POST (DD/MM/YYYY)
SERVICEMAN (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 ARRANGED
ARRANGEMENT OF SCRIBE ? BY SSC, INDICATE MEDIUM
- - -
18. ARE YOU ALSO APPLYING FOR THE POST OF JUNIOR 19. DO YOU POSSESS EQ FOR THE POST OF JUNIOR
STATISTICAL OFFICER (MoSPI)? STATISTICAL OFFICER (MoSPI)?
NO -
20. WHETHER SEEKING AGE RELAXATION ? 20.1 IF YES, AGE RELAXATION CODE
NO -
21. HIGHEST EDUCATIONAL QUALIFICATION
B. TECH (14)
22. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
GRADUATION
STATE/ UT OF
PASSING NAME OF
STATUS BOARD/ ROLL NO PERCENTAGE CGPA
YEAR BOARD/ UNIVERSITY
UNIVERSITY
PASSED 2014 WEST BENGAL NIT DURGAPUR (NITDGP) 10/CSE/17 - 7.43
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
PITAMBER BHAWAN MAHILA COLLEGE ROAD PITAMBER BHAWAN MAHILA COLLEGE ROAD
GANGASAGAR CHOWK GANGASAGAR CHOWK
DISTRICT: MADHUBANI DISTRICT:MADHUBANI
STATE: BIHAR STATE: BIHAR
PIN : 847211 PIN : 847211
MOBILE NO: 8448714236 EMAIL: bhanu1192@icloud.com
27. DATE ON WHICH THE UPLOADED PHOTOGRAPH 28. WHETHER THE DATE OF PHOTOGRAPH IS CLEARLY
HAS BEEN TAKEN PRINTED ON THE PHOTOGRAPH
(DD/MM/YYYY):
13/01/2021 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.
PRINT TAKEN ON: 01/02/2021 1:31:26 PM IP ADDRESS:106.208.226.155