STAFF SELECTION COMMISSION
BLOCK NO. 12, CGO-COMPLEX, LODHI ROAD, NEW DELHI
110003
COMBINED HIGHER SECONDARY (10+2) LEVEL
EXAMINATION 2018
REGISTRATION NO: 94000391265
APPLICATION IS PROVISIONALLY ACCEPTED
1. NAME AS PER
2. NEW/CHANGED
MATRICULATION 3. FATHER'S NAME 4. MOTHER'S NAME
NAME
CERTIFICATE
BISWAMITRA BHOI - SURESH BHOI AHALYA BHOI
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2019 7. GENDER
24/02/1991 28.5 MALE
9.1 .IF YES, TYPE OF
9. WHETHER PERSON WITH
8. CATEGORY DISABILITY (OH, HH,VH,
DISABILITY (PWD) ?
OTHERS)
OBC NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA RIGHT HAND TEL
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
BOARD OF SECONDARY EDUCATION, ODISHA 57MC007 2007
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )
SAMBALPUR (4609) ROURKELA (4610) BHUBANESHWAR (4604)
17. WHETHER 12th STANDARD PASS IN SCIENCE STREAM WITH
16. MEDIUM OF TYPE TEST MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR
EQUIVALENT (FOR C&AG AS DATA ENTRY OPERATOR)
ENGLISH NO
18.1. HAVE YOU ALREADY
JOINED A CIVIL POST BY 18.3. DATE OF DISCHARGE
18.WHETHER EX- 18.2. LENGTH OF SERVICE IN
AVAILING BENEFIT OF FROM ARMED FORCES
SERVICEMAN (ESM)? ARMED FORCES ( IN YEARS )
RESERVATION FOR EX- (DD/MM/YYYY)
SERVICEMAN (ESM) :?
NO - - -
19.1 DO YOU SUFFER 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)?
NO
19.5 IF SCRIBE IS TO BE
19.4 WILL YOU MAKE YOUR OWN
19.3 WHETHER SCRIBE IS REQUIRED ARRANGED BY SSC, INDICATE
ARRANGEMENT OF SCRIBE?
MEDIUM
NO - -
20. WHETHER SEEKING AGE RELAXATION? 20.1 IF YES,INDICATE CODE
YES 02-OBC
21. EDUCATIONAL QUALIFICATION
MA
22. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?
-
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 ?
NO
ADDRESS DETAIL
24. POSTAL ADDRESS 25. PERMANENT ADDRESS
AT/JHIMBAHAL PO/KUNDAKHAI VIA/MELCHHAMUNDA AT/JHIMBAHAL PO/KUNDAKHAI VIA/MELCHHAMUNDA
DISTRICT: BARGARH (BARAGAR) DISTRICT: BARGARH (BARAGAR)
STATE: ODISHA STATE: ODISHA
PIN: 768035 PIN: 768035
MOBILE NO : 9777946878 EMAIL ID : biswamitrabhoi5@gmail.com
SIGNATURE
FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE
NOT EXEMPTED 100 CPP0406539 21/03/2019
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: 21/03/2019 1:29:01 AM
