-/ANNEXURE-I

STAFF SELECTION COMMISSION

vBE (+) -2014

COMBINED HIGHER SECONDARY LEVEL (10+2) EXAMINATION-2014

BE{ {F BE x] nA MA +xn / BE Bvx {BBE {f * BD (

) Jx BE A x BE {x BE |M *

Please read instructions in the Notice of the Examination/Annexures carefully. Use Blue or Black ball pen to write in the box (
1.

{F BExp BE x / Name of the Examination Centre

2. {F BExp BEb / Examination Centre Code

3. =nB BE { x (+OV ) ]BEx |h {j nA MA x BE +x +F J * x BE n M BE S ABE BD BE J U n *

Candidates Full Name (in English). Write in Capital Letters exactly as in Matriculation Certificate. Leave one box blank between every two parts of the name.

{i BE x (+OV BE +F J) / Fathers Name (Write in Capital Letters in English)

4.

5. i BE x (+OV BE +F J) / Mothers Name (Write in Capital Letters in English)

Vx BE iJ / Date of Birth

6.

7. M / Gender
(J 1-j AB 2-{)
(Write 1-Female & 2- Male)

nx / Day

cx /Month

/Year
10.1 +{ i{B xBE c ?

10. gh / Category

8.

/Nationality

9.

(J 1-i AB 2-+x)
(Write 1-Indian & 2 - Others)

BE / Fee

(J 1-BE BE Mix n 2- U] BE nB BE)

(Write 1-Fee paid & 2- Exemption claimed)

11. BD +{ BE BBEM c ?
Whether PH ?

10.2. i {B xBE BE A For Ex-Serviceman

If Ex-serviceman
(J 9-+x,1 +V,2 +VV AB 6-+{B)
(Write 9-General, 1-SC, 2-ST, 6-OBC)

B {i i l/Date of Discharge
(nx/Day cx /Month /year)

12. BD + U] Sci c?

11.1 n c, BEb +BEi BE

If yes, indicate code

Whether seeking Age relaxation?

(J 4-+.B., 5-g.B., 7- o. B.)

(Write 4-OH, 5-HH,7-VH )
12.2

3 J
Write 3 in the box

(J 1-c AB 2-xc)
(Wrire 1-Yes, 2-No)

[ /Year]

B +Bv / Length of Service

12.1 n c, BEb +BEi BE/ If yes, indicate code

(n +B E BE JiBE BEb +BEi BE) /(Write two digit numeric code)

(J 1-c AB 2-xc) (Write -1-Yes, 2-No)

01.08.2014 BE + / Age as on 01.08.2014

13.{n BE |lBEi
[ . . .

L ... D ]

Preference for Post [ Write L for LDC and D for DEO]

/ Years
14.

( -1, -2 )

Indicate medium for Typing Test

(English-1, Hindi-2)

cx / Months
15.

n vi/ c, i BD 15.1. n c, v +B Ei BE
( +OV BE A 1, cxn BE A 2 J )
+{BE |{BE BE +BBEi c ?
If yes, indicate medium,
(J 1-c, 2-xc)
If VH/Cerebral Palsy whether scribe is required?
(Write 1-yes, 2-No)

17. FBE Mi Educational Qualification

BEb +BEi BE Indicate Code

nx / Days

Subject Code

(Write 1- English, 2-Hindi)

+BE BE |ii (%)

Percentage (%) of Marks

16. BD +{ +{JBE c?

(J 1-c AB 2-xc)
Whether belong to Minority
Communities ? (Write 1-Yes, 2-No)

v (+OV-1, cxn-2 B +x-3)

Medium ( English-1, Hindi-2, Others-3)

18. BE +xB BE BBh Details of work Experience / Govt. Service :

l BE x
Name of the Organisation(s)

{nx

Designation

19. {i: +{x x ci {j BBc BE { {i +OV BE +F cxn x

BE {x J *
Address: Write your complete Communication Address including your
Name in English Capital Letters or Hindi with Blue or Black Ball Pen.
Name___________________________________________________
Address_________________________________________________

___________________________________________________________
___________________________________________________________
PIN:
./ Mobile No. : .........................................................

BE BE B Bh
Name of the Duty(ies)

20. {E]O{E
4 x 5 +BE BE
c c JS M {E]O{E
c ~BE fM S{BE *
(]{ x BE * {E] BE
i{i x BEBA)
Photograph
Paste here firmly your recent
photograph
(4 c.m.X 5c.m)
(Do not staple. Do not get the
Photograph attested)

BE BE +Sv /
/From

Period of Service
iBE / To

+xEBE (BEB BE |M ci)

Roll Number (for Office use only)

21.=nB BE ciF

Signature of the Candidate in the left

Box

/Email ID:.....
(Page 1 of 2)

22. /Declaration

..


Space for cancellation
stamp by post office
after affixing CRF
stamp

23. ..

Space for CRF Stamp

Rs. 100.00 ..



( )

Paste here firmly CRF

Stamp of Rs 100.00
denomination and get
it cancelled from the
post office where
purchased.

( Do not Staple)

(i) , /
I have read the provisions in the Notice of the examination carefully and hereby undertake to
abide by them.
(ii) / , ,
/
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational
qualifications etc., prescribed for admission to the examination.
(iii) / /
/

I also declare that I do not stand debarred by SSC/UPSC as on date and have never been
convicted by any court of law. I also declare that no charge sheet is pending against me in any
court of law. Further declare that I have never been dismissed or removed from Govt. Service or
my service been terminated during probation.
(iv) *
/ 3
,
* For Central Govt. Civilian Employee seeking age relaxation.
I declare that I am a Central Govt. Civilian Employee and completed 3 years of regular service or
regular length of service stipulated in the Notice of the examination on or before date of closing
of submitting application form given in the Notice.
(v) *
/ 8.9.1993
36012/22/93- ( )

, . 3 / ( )
/

*For Candidate belonging to OBC.

I declare that I belong to the community which is recognized as a backward class by the Govt.
of India for the purpose of reservation in services as per order contained in Deptt. of Personnel
and Training Office Memorandum No.36012/22/93-Estt.(SCT) dated 8.9.1993. I also declare that I do
not belong to the person/sections (creamy layer) mentioned in column 3 of the schedule of the
OM mentioned above and modified vide Govt. of India DOPT OMs mentioned in the Notice. I
further declare that I am in possession of OBC Certificate in the prescribed format given in the
Notice of the examination or will submit valid OBC Certificate at the time of Skill Test/Typing Test
as per the provision of the Notice.
(vi)
/ /
For Candidate belonging Ex-Serviceman
I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of
examination.
(vii) /
, / /
/
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.

=nB BE ciF
Signature of candidate

lx/Place: ..
D

iJ/Date:
* n M x c i c <x BE] n *
* Strike off this sentence if not applicable

+ciFi +Bnx {j BE q BE n VM
Unsigned application will be rejected
(Page 2 of 2)