STAFF SELECTION COMMISSION
BLOCK NO. 12, CGO-COMPLEX, LODHI ROAD, NEW DELHI
110003
COMBINED HIGHER SECONDARY (10+2) LEVEL
EXAMINATION, 2023
REGISTRATION NO: 50004412154
APPLICATION RECEIVED (CONTENTS NOT VERIFIED)
1. NAME AS PER 2. NEW/ CHANGED
NAME 3. FATHER'S NAME 4. MOTHER'S NAME
MATRICULATION CERTIFICATE
BHAVESH - VILAS SINDHUBAI
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2023 7. GENDER 8. CATEGORY
04/11/1997 25.8 MALE SC
9. WHETHER PERSON WITH BENCHMARK DISABILITY
9.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
(PwBD) ?
NO -
10. NATIONALITY 11. MARK OF VISIBLE IDENTIFICATION
CITIZEN OF INDIA THE FOOT HAS A MARK
13. MATRICULATION (10th 14. MATRICULATION (10th
12. MATRICULATION (10th CLASS) EXAMINATION BOARD
CLASS) ROLL NO CLASS) YEAR OF PASSING
MAHARASHTRA STATE BOARD OF SECONDARY AND
D-125162 2013
HIGHER SECONDARY EDUCATION
15. PREFERENCE OF EXAMINATION CENTRES
EXAMINATION CENTRE EXAMINATION CENTRE EXAMINATION CENTRE
(FIRST PREFERENCE ) (SECOND PREFERENCE ) (THIRD PREFERENCE)
SURAT ( 7007 ) JALGAON ( 7214 ) PUNE ( 7208 )
16. MEDIUM FOR COMPUTER BASED EXAMINATION(CBE):
MARATHI
18. WHETHER 12TH STANDARD PASS IN SCIENCE STREAM WITH
MATHEMATICS AS A SUBJECT FROM A RECOGNIZED BOARD OR EQUIVALENT
17. MEDIUM FOR TYPING TEST:
(FOR DEOs IN DEPARTMENT/ MINSTRY MENTIONED AT PARA 8.1 OF THE
NOTICE):
HINDI NO
19.1. WHETHER YOU ARE AN EX- 19.2. DATE OF JOINING THE ARMED 19.3.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 - -
19.4. LENGTH OF SERVICE IN THE 19.5. HAVE YOU ALREADY JOINED A 19.6. DATE OF JOINING TO CIVIL POST
ARMED FORCES CIVIL POST BY AVAILING BENEFIT OF (DD/MM/YYYY)
RESERVATION FOR EX-SERVICEMAN
(ESM) ?
- - -
20. 1. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF BLINDNESS (VH)?
-
20.2. 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)?
-
20.3. DO YOU HAVE A PHYSICAL LIMITATION TO WRITE AS PER PARA 7.2 OR PARA 7.3 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
20.4. WHETHER SCRIBE IS REQUIRED ? 20.5. WILL YOU MAKE YOUR OWN 20.6. IF SCRIBE IS TO BE ARRANGED
ARRANGEMENT OF SCRIBE ? BY SSC, INDICATE MEDIUM
- - -
21.1. WHETHER SEEKING AGE RELAXATION ? 21.2. IF YES, AGE RELAXATION CODE
YES
01-SC/ST
22. HIGHEST EDUCATIONAL QUALIFICATION
MA (25)
23. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION
12TH STANDARD
STATE/ UT OF NAME OF BOARD/
STATUS PASSING YEAR ROLL NO PERCENTAGE CGPA
BOARD/ UNIVERSITY UNIVERSITY
MAHARASHTRA
STATE BOARD OF
SECONDARY AND
PASSED 2014 MAHARASHTRA S096226 58 -
HIGHER
SECONDARY
EDUCATION
24. 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
25. CORRESPONDENCE ADDRESS 26.PERMANENT ADDRESS
SAMATA HOUSING SOCITEY SAMATA HOUSING SOCITEY
DISTRICT: NANDURBAR DISTRICT:NANDURBAR
STATE: MAHARASHTRA STATE: MAHARASHTRA
PIN : 425412 PIN : 425412
MOBILE NO: 9075148726 EMAIL: bhaveshpawar543@email.com
28. WHETHER THE PHOTOGRAPH HAS BEEN TAKEN ON OR AFTER 09-FEBRUARY-2023?
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.
4. I AGREE TO AUTHORIZE SSC TO USE MY AADHAR DATA FOR VERIFICATION PURPOSE.
PRINT TAKEN ON: 31/05/2023 9:44:03 AM IP ADDRESS: 103.232.25.220
