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: 85000318247
APPLICATION IS PROVISIONALLY ACCEPTED
1. NAME AS PER 2. NEW/CHANGED 3. FATHER'S NAME 4. MOTHER'S NAME
MATRICULATION NAME
CERTIFICATE
SUSHILA BHAGAT - MANGAL SAI BHAGAT LALITA BHAGAT
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01-01-2020 7. GENDER
15/02/1991 28.1 FEMALE
10. MARK OF VISIBLE
8. CATEGORY 9. NATIONALITY
IDENTIFICATION
MOLE IN THE RIGHT SIDE OF
ST CITIZEN OF INDIA
FACE
11. MATRICULATION (10th CLASS) EXAMINATION 12. MATRICULATION (10th 13. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
CHHATTISGARH BOARD OF SECONDARY
82101276 2008
EDUCATION
14. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )
RAIPUR ( 6204 ) BHILAI NAGAR ( 6206 ) BILASPUR ( 6202 )
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- MECHANICAL ENGINEERING
20. QUALIFICATION DETAILS
HIGHEST TECHNICAL QUALIFICATION RELEVANT TO SUBJECT/ STREAM
THE POST OF INTEREST
BE MECHANICAL ENGINEERING
21. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?
-
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
BOURIPARA SHIKARI ROAD ORANWPARA AMBIKAPUR VILLAGE VISHUNPUR KHALPARA POST POKSARI
TEHSIL BATAULI
DISTRICT: SURGUJA DISTRICT:SURGUJA
STATE: CHHATTISGARH STATE: CHHATTISGARH
PIN : 497001 PIN : 497101
MOBILE NO: 9516092011 EMAIL: sushilabhagat91@gmail.com
SIGNATURE
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.
PRINT TAKEN ON: 09/09/2019 8:46:19 PM
