STAFF SELECTION COMMISSION

BLOCK NO. 12, CGO COMPLEX, LODHI ROAD, NEW DELHI

110003

MULTI TASKING STAFF (MTS) EXAMINATION 2019

REGISTRATION NO: 40000365723

APPLICATION IS INCOMPLETE
1. NAME AS PER 2. NEW/CHANGED
MATRICULATION 3. FATHER'S NAME 4. MOTHER'S NAME
NAME
CERTIFICATE
ANIL KUMAR - JOGI RAM ROSHNI DEVI
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2019 7. GENDER
11/10/1996 22.9 MALE
8. CATEGORY 9. ID NUMBER 10. NATIONALITY
UR 83XXXXXXXX59 CITIZEN OF INDIA
11. MARK OF VISIBLE IDENTIFICATION : CUT MARK ON EYEBROW
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
BOARD OF SCHOOL EDUCATION HARYANA 2211407575 2012
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )

1403 - PATIALA 1601 - CHANDIGARH 1406 - MOHALI

16.1. HAVE YOU ALREADY
JOINED A CIVIL POST BY 16.3. DATE OF DISCHARGE
16.WHETHER EX- 16.2. LENGTH OF SERVICE IN
AVAILING BENEFIT OF FROM ARMED FORCES
SERVICEMAN (ESM)? ARMED FORCES ( IN YEARS )
RESERVATION FOR EX- (DD/MM/YYYY)
SERVICEMAN (ESM) :?
NO - - -
17. WHETHER PERSON WITH DISABILITY 17.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
(PWD) ?
NO -
18.1 WHETHER SUFFERING FROM CEREBRAL PALSY
-
18.2 DO YOU HAVE A PHYSICAL LIMITATION TO WRITE AND SCRIBE IS REQUIRED TO WRITE ON YOUR BEHALF
(CERTIFICATE TO THIS EFFECT FROM THE CHIEF MEDICAL OFFICER/ CIVIL SURGEON & MEDICAL
SUPERINTENDENT OF A GOVERNMENT HEALTH CARE INSTITUTION AS PER NOTICE OF THE EXAMINATION
WOULD BE REQUIRED AT THE TIME OF EXAMINATION)?
-
 18.3 WHETHER SCRIBE IS REQUIRED 18.4 WILL YOU MAKE YOUR OWN 18.5 IF SCRIBE IS TO BE
ARRANGEMENT OF SCRIBE? ARRANGED BY SSC, INDICATE
MEDIUM
- - -
19. WHETHER SEEKING AGE RELAXATION? 19.1 IF YES,INDICATE CODE
NO -
20. STATE(S) / U.T. PREFRENCE CODE
C,A,E,F,G,D,1,H,J,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X
21. EDUCATIONAL QUALIFICATION
INTERMEDIATE/ HIGHER SECONDARY/ 10+2
22. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?
YES
23. 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
24. POSTAL ADDRESS 25. PERMANENT ADDRESS
VPO ROHERA BHEDDI PATTI VPO ROHERA BHEDDI PATTI
DISTRICT: KAITHAL DISTRICT: KAITHAL
STATE: HARYANA STATE: HARYANA
PIN: 136044 PIN: 136044
MOBILE NO. : 8053404682 EMAIL ID: anil39257@gmail.com
SIGNATURE

FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE

NOT EXEMPTED 100 - -
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.
PRINT TAKEN ON: 20/05/2019 2:18:27 PM