Scribd
Upload
24 views3 pages

Applicationform Draft Print For All

The document is a provisional acceptance notice for Sampa Sarkar's application for the Combined Higher Secondary Level Examination 2021. It includes personal details such as date of birth, gender, educational qualifications, and examination center preferences. The applicant has declared all information to be true and is willing to serve anywhere in India.

Uploaded by

gourabpramanick321
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
24 views3 pages

Applicationform Draft Print For All

The document is a provisional acceptance notice for Sampa Sarkar's application for the Combined Higher Secondary Level Examination 2021. It includes personal details such as date of birth, gender, educational qualifications, and examination center preferences. The applicant has declared all information to be true and is willing to serve anywhere in India.

Uploaded by

gourabpramanick321
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
You are on page 1/ 3

STAFF SELECTION COMMISSION

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


110003

COMBINED HIGHER SECONDARY (10+2) LEVEL


EXAMINATION, 2021

REGISTRATION NO: 40004646918

APPLICATION IS PROVISIONALLY ACCEPTED


1. NAME AS PER 2. NEW/ CHANGED 3. FATHER'S NAME 4. MOTHER'S NAME
MATRICULATION CERTIFICATE NAME
SAMPA SARKAR - DULAL SARKAR SARMILA SARKAR
6. AGE AS ON
5. DATE OF BIRTH (DD/MM/YYYY) 7. GENDER 8. CATEGORY
01/01/2022
12/01/2003 18.11 FEMALE 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 SMALL CUT IN RIGHT HAND
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
WEST BENGAL BOARD OF SECONDARY EDUCATION 402972N 0028 2018
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTRE EXAMINATION CENTRE EXAMINATION CENTRE
(FIRST PREFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE)
KOLKATA ( 4410 ) KALYANI ( 4419 ) BURDWAN ( 4404 )
17. WHETHER 12TH STANDARD PASS IN SCIENCE STREAM WITH
16. MEDIUM FOR TYPING TEST: MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR
EQUIVALENT(FOR C&AG AS DATA ENTRY OPERATOR):
ENGLISH NO
18.1. WHETHER YOU ARE AN EX- 18.2. DATE OF JOINING THE ARMED 18.3.DATE OF DISCHARGE/ LIKELY
SERVICEMAN (ESM) OR SERVING IN FORCES (DD/MM/YYYY) DATE OF DISCHARGE FROM ARMED
THE ARMED FORCES? FORCES (DD/MM/ YYYY)

NO - -
18.4. LENGTH OF SERVICE IN THE 18.5. HAVE YOU ALREADY JOINED A 18.6. DATE OF JOINING TO CIVIL
ARMED FORCES CIVIL POST BY AVAILING BENEFIT POST (DD/MM/YYYY)
OF RESERVATION FOR EX-
SERVICEMAN (ESM) ?
- - -
19.1. WHETHER SUFFERING 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) ?
-
19.3. WHETHER SCRIBE IS REQUIRED 19.4. WILL YOU MAKE YOUR OWN 19.5. IF SCRIBE IS TO BE ARRANGED
? ARRANGEMENT OF SCRIBE ? BY SSC, INDICATE MEDIUM
- - -

20.1. WHETHER SEEKING AGE RELAXATION ? 20.2. IF YES, AGE RELAXATION CODE

NO
-
21. HIGHEST EDUCATIONAL QUALIFICATION
BA (5)
22. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
12TH STANDARD
STATE/ UT OF NAME OF BOARD/
STATUS PASSING YEAR ROLL NO PERCENTAGE CGPA
BOARD/ UNIVERSITY UNIVERSITY
WEST BENGAL
COUNCIL OF
HIGHER
PASSED 2021 WEST BENGAL 431022 1017 35.8 -
SECONDARY
EDUCATION,
WEST BENGAL
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
POURA STADIUM ROAD SANTIPUR NADIA POURA STADIUM ROAD SANTIPUR NADIA

DISTRICT: NADIA DISTRICT:NADIA


STATE: WEST BENGAL STATE: WEST BENGAL
PIN : 741404 PIN : 741404
MOBILE NO: 8101764562 EMAIL: nb89623@gmail.com
27. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 01-NOV-2021?
YES
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
EXEMPTED - - -
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: 05/03/2022 9:52:49 AM IP ADDRESS: 117.226.241.48

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy