/ANNEXURE-II

STAFF SELECTION COMMISSION

/APPLICATION FORM
./Advt. No. NR /1/2012
/ (
)
Please read instruction in the Notice of the Examination carefully. Use Blue or Black ball pen to write in the box (

/ Name of the post

1.

2. in

2.

. Post Cat. No.

3. ( )

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

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

5.

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

6. / Date of Birth
/Day /Month

/Year

7. / Gender

8. /Nationality

9. / Fee

(- 1 2-)
(Write 1-Female & 2- Male)

(- 1 2- )
(Write 1-Indian & 2 - Others)

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

10. / Category

10.1 ?

( 9 ,1, 2 6 )

If Ex-serviceman ?
(- 3- )
(Write 3- Ex-Serviceman)

(Write 9-UR,1-SC, 2-ST,

6-OBC)

12. ?

Whether seeking Age relaxation?

11. ?
Whether PH ?

11.1 ,
If yes, indicate code

( 1- 2- )
(Wrire 1-Yes, 2-No)

( 4-, 5-.., 7-..)

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

12.1 ,

12.2 12.10.2012 / Age

If yes, indicate code

(
Write two digit numeric code)
(Please see Annexure-I)

( 1- 2-)
(Write 1-Yes, 2-No)

14. ?
(- 1 , 2- )
Whether belong to Minority Communities
as per Govt. Orders? (Write 1-Yes, 2-No)

13.1 For Ex-Serviceman

/ Length of Service

[ /Year]

/Date of Discharge
/ Day

/Month /Year

16.2
16.1
16. / Essential Qualification
Indicate Code [See Appendix-VII] Main Subject Code
[See Appendix-VIII]
E.Q, I
E.Q. II
E.Q. III
18.

Higher Qualification Code

I

/ Years / Months / Days

(%)
(%) of Marks

15. ... ?
(- 1 , 2- )
Whether Cent. .Govt. Civilian
Employee ?(Write 1-Yes, 2-No)

17.
Desirable Qualification Code

D.Q, I

D.Q. II

D.Q. III

17.1
Subject Code

19. / Details of work Experience

18.1
Subject Code

Name of the Orgn.(s)

II

Designation

Name the specific fields

Period of Service

III

/ Years / Months
/ Years / Months
20. :

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

Name__________________________________________________

Address_______________________________________________
_______________________________________________________

21. :
4 . .x 5 ..


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

(
)
Roll Number ( for Office
use only)

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

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

22. ( )
Signature of the Candidate in the
above Box (Only in running Hand)

Page 1 of 2

23. / Declaration
..


Space for cancellation
stamp by post office
after affixing CRF
stamp

24. ..

Space for CRF Stamp

Rs. 50.00 ..



( )

Paste here firmly CRF

Stamp of Rs. 50.00
denomination and get
it cancelled from the
post office where
purchased.
( Do not Staple)

23. BE. .
BE ]BE]
BE A
lx
Space for 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)

VxB
ci
lx
(i ) BE
..
BE
q
BE

]BE]

/
Space
by post
after affixing CRF stamp
for
cancellation
stamp

office

I have not submitted any other application for this post. 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 / ( )
/
*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.
(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.

25.
( )
Signature of candidate ( only in running hand)

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

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

Unsigned application will be rejected

(Page 2 of 2)