-/ANNEXURE- I

STAFF SELECTION COMMISSION

RECRUITMENT OF SUB INSPECTOR IN DELHI POLICE & CAPFs,
ASSISTANT SUB INSPECOR IN CISF EXAMINATION 2015

/ (

Please read instruction in the Notice of the Examination/Annexure-II carefully. Use Blue or Black ball pen to write in the box (
1. / Name of the Examination Centre

2. / Center Code

3. ( )

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

4. ( ) / Father's Name (Write in Capital Letters in English)

5.

6.

( )/ Mother's Name (Write in Capital Letters in English)

/ Date of Birth

/ Day /Month

7. / Gender
(- 1 2-)
(Write 1-Female & 2- Male)

/Year

10. / Category

10.1 ?

( 9 ,1, 2 6 )

Whether Ex-serviceman ?

(Write 9-General, 1-SC, 2-ST, 4-OBC

for Delhi police only, 6-OBC for all
other posts, (see para 3 of notice)

(- 3- )
(Write 3- Ex-Serviceman)

/Date of Discharge

[ /Year]
/ Day

/Month /Year

15. Educational Qualification

Indicate Code

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

Delhi Police.
Write-1 Yes, 2 No.

( 1 , 2- )

11. Preference of Posts

(A,B,C,D,E,F,G,)

Please see para 1 of the notice.

12.2. 01.01.2015
Age as on 01.1.2015

If yes, indicate code

( )
(Write two digit numeric code)

13. For Ex-Serviceman

9.

10.2. Whether Departmental Candidate of

12.1 ,

12. ?
Whether seeking Age relaxation ?
( 1 , 2- )
(Write -1-Yes, 2-No)

/ Length of Service

8. /Nationality
(- 1 2- )
(Write 1-Indian & 2 - Others)

/ Years

/ Months

/ Days

13.1 Whether eligible for special

quota for Exs for Delhi Police

14. ?
( 8 )

(Write 1 for Yes 2 for No)

Whether belong to Minority Communities

as per Govt. Orders? (Write 8 for minority

(Please see para 2 of the notice)

community)

(%)
Percentage (%) of Marks

Subject Code

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

16. / Details of work Experience / Govt. Service rendered

Name of the Organisation(s)

Designation

17. :

Address: Write your complete Communication Address including your
Name in English Capital Letters or Hindi with Blue or Black Ball Pen.

Name__________________________________________________

Address_______________________________________________
_______________________________________________________

Name of the Duty(ies)

18. :
4 . .x 5 ..


(
)
Photograph
Paste here firmly your recent
photograph
(4 cm.X 5 cm)
(Do not staple. Do not get the
Photograph attested)

________________________________________________________
________________________________________________________
PIN:
17.1 ./ Mobile No. : .......................................................

- / Email :...................................................................

19. ( )
Signature of the Candidate in the
above Box

/
/From

Period of Service
/ To

20. ( )
Roll Number ( for Office use only)

21. / Declaration
..


Space for cancellation
stamp by post office
after affixing CRF stamp

22. ..

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)

BE. . BE ]BE]
S{BEx BE n bBEP
u q BE Vx B
]BE] ci lx
23. BE. .
BE
Space
for ]BE] BE
cancellation
stamp by
A lx
post office after
Space
for CRF Stamp
affixing CRF stamp

r 100.00 BE BE.
.
BE ]BE] c ~BE fM
S{BEA il bBEP
q BE n Vc Bc
Jn M c *
(]{ x BE)

Paste here firmly

CRF Stamp of r
100.00
denomination and
get it cancelled from
the post office
where purchased.
( Do not Staple)

(i ) BE
S
BEn
bBEP
uq BE
Vx
B

ci lx
/
. .
BE]BE]
{BEx
]BE]
Space
by post
affixing

for
cancellation
stamp

office
after

CRF stamp
I have not submitted any other application for this examination. I am aware that if I contravene
this rule, my application will be rejected summarily by the Commission.
(ii) , /
I have read the provisions in the Notice of the examination carefully and hereby undertake to
abide by them.
(iii) / , ,
/
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational
qualifications etc., prescribed for admission to the examination.
(iv) / /
/

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.
(v) *
/ 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.
(vi) *
/ 8.9.1993
36012/22/93- ( )

, . 3 / ( )
/ 4() /

*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 will produce valid OBC certificate as per para 4(C) of notice of the
examination in the prescribed format.
(vii)
/ /
For Candidate belonging Ex-Serviceman
I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of
examination.
(viii) /
, / /
/
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.
( )
Signature of candidate

/Place: .............................................
D

/Date:
*
* Strike off this sentence if not applicable

Unsigned application will be rejected
(Page 2 of 2)