06.

Date of Birth (DD MM YYYY)

08. Category
10. *If, person with disability (40% & above)
BL/LV HI LM/CP
11. Whether Scribe is required
(if Yes against point no. 10)
07. Gender
Female Male
12. Whether Exempted Category
09. **If Departmental Candidate
13. Whether ExServiceman 14. If Yes against point no. 13.
Mention no. of
Years in Service
17. Mobile No.
16. Email ID in Engl ish Capital Letter without space
03. Candidate s Full Name in Engl ish Capital Letter as in Madhyamik or equivalent Certificate. Leave a box blank between any two part of the name. (Don t write Mr. / Dr. etc. )
04. Father s Name in Engl ish Capital Letter. (Dont write Late / Mr. / Dr. etc. )
05. Mother s Maiden Name in Engl ish Capital Letter. (Don t write Late / Mrs. / Ms. / Dr. etc. )
WEST BENGAL STAFF SELECTION COMMISSION
Mayukh Bhaban, Salt Lake, Kolkata - 700091.
Please read the Notice of the Recruitment / Instruction to Candidates in the website www.wbssc.gov.in carefully before filling up of the form.
Its a Machine Readable, ICR/OMR Compatible Form. Use Black ball point pen to write in the box & filling up the circle.
Write carefully. Dont touch the letter or number in the box.
Application for : Special Recruitment Drive, 2014
02. Name of the Centre Opted : *** Centre Code :
15. *** Qual ification (Essential and Additional, if any) Code Year of Passing Percentage (%) of Marks
Name of Examination
Madhyamik or Equivalent 0 2 1
2
3
4
.
.
.
.
01. Put Sl. No. against each
Lower Division Krishi Prajukti Veterinary
post in order of Preference,
Clerk/Assistant
Amin Bhumi Sahayak Draftsman
Sahayak Pharmacist
i.e, 1, 2, 3, 4 etc.
Yes No
*** For Codes, pl ease refer i nstructi ons overleaf.
** Persons at least two years in Govt. Servi ce wi l l only be considered as Departmental Candi dates. Page 1 of 2
* BL/LV Bli ndness or Low Vi si on, HI Heari ng Impai rment, LM/CP Loco Motor Di sabi li ty or Cerebral Pal sy.
SC ST
Yes No Yes No Yes No
21. Ful l Signature of the Candidate in the box given below
(onl y in Running Hand) without touching the box
Control No. (for Office Use Only)
without touching the box
19. Address : Write your complete communication Address including your name in Engl ish Capital Letter
Name ________________________________________________________________________________
C/O __________________________________________________________________________________
Address _______________________________________________________________________________
P. O. : ________________________________________ P.S. :____________________________________
District : ___________________________________ PIN :
State : _________________________________________
20. Photograph
Paste here firmly your recent
Photograph (4.5cm X 3.5cm)
(Do not staple. Do not get the
Photograph Attested /
Self Attested)
(Dont touch the Photo Edge
to the box border)
22. Application No.
H. S. Level Madhyamik Level
18. *** Preference of Districts for Posting (Write District Code)
Preference 1 Preference 2
for
KPS
for
LDC /LDA

23.












24.









*****************************************************************************************************************

Important Instructions
1. Please do not attach any document.
2. Form must be printed in actual size on both side of a 75 GSM A4 size white paper.
3. This application form must be downloaded from the Commissions website www.wbssc.gov.in as each downloaded application form shall
bear a BAR CODE and NUMBER. This BAR CODE and NUMBER will be treated as REGISTRATION NUMBER after successful
acceptance of the application form.
4. No form without the BAR CODE and NUMBER as stated shall be accepted by the Commission.
5. Candidates shall not use any photocopied/ typed / hand written/ scanned copy of the said application form as the BAR CODE and NUMBER
will be same for such copies of form. All such applications will be rejected summarily.
6. Applications shall be rejected summarily without full signature of the candidate in running hand only on the designated boxes and on the e-
payment receipt.
7. Please keep a photocopy of the Application Form after proper filling up and affixing the postal e-payment receipt for future reference with
the Commission, if any.
8. Candidates should visit Commissions website www.wbssc.gov.in for detailed instructions and sample filled up application form.
9. While writing in the box or marking your choice, darken the circles as shown in the sample
10. Properly filled application should be sent by Post to:
The Secretary Cum Controller of Examinations,
West Bengal Staff Selection Commission,
Mayukh Bhaban, Salt Lake, Kolkata 700091.

A. Centre Code. (for point no. 02 in page 1)
01-Bankura, 02-Bardhaman, 03-Birbhum, 04-Darjeeling, 05-Howrah, 06-Hooghly, 07-Jalpaiguri, 08-Cooch Behar, 09-Malda, 10-Paschim Medinipur,
11-Purba Medinipur, 12-Murshidabad, 13-Nadia, 14-Purulia, 15-North 24 Parganas, 16-South 24 Parganas., 17 - Dakshin Dinajpur,18 - Uttar
Dinajpur, 19-Kolkata North, 20-Kolkata South, 21-Salt Lake, 22-Siliguri, 23-Alipurduar, 24-Asansol.
B. District Code for Preference of Districts for Posting. (for point no. 18 in page 1)
01-Bankura, 02-Bardhaman, 03-Birbhum, 04-Darjeeling, 05-Howrah, 06-Hooghly, 07-Jalpaiguri, 08-Cooch Behar, 09-Malda, 10-Paschim Medinipur,
11-Purba Medinipur, 12-Murshidabad, 13-Nadia, 14-Purulia, 15-North 24 Parganas, 16-South 24 Parganas., 17 - Dakshin Dinajpur,18 - Uttar
Dinajpur, 19-Kolkata, 20-Alipurduar.

C. Educational Qualification (Basic) Code. (for point no. 15 in page 1)
02 Madhyamik or Equivalent, 03 Higher Secondary or Equivalent, 04 Pass Graduate, 05 Hons. Graduate, 06 Post Graduate, 07 - Ph.D.,
08 - B.Tech/B.E./Degree Engineer, 09 - Diploma Engineer, 10 - Diploma in the related Trade, 11 - National Trade Certificate in the related Trade. 12
- Certificate of Senior Surveyorship from the West Bengal Survey Institute, Bandel, 13 - National Trade Certificate on Surveyorship from the
Industrial Training Institute or its equivalent. 14- Certificate in Two Years Diploma Course in Veterinary Pharmacy under Board of Veterinary
Education, West Bengal or its equivalent recognised by the Board of Veterinary Education, West Bengal 15 Certificate in-service abridged
(condensed) course on Diploma in Veterinary Pharmacy.
Page 2 of 2
.................................................................................................................
(i) I possess all the Essential Qualifications for the Post.
(ii) I am an Indian National.
(iii) 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.
(iv) I have never been debarred from any examination conducted by any recruitment Commission/ Board/ Agency of the Govt. of West
Bengal/ Govt. of India .
Place: ........................................................

Date:


Full Signature of the Candidate (only in Running Hand)


Affix the Postal e-payment receipt here
and
put your full signature on it.

D D Y Y Y Y M M