-/ANNEXURE-I

STAFF SELECTION COMMISSION

( C D) -13

STENOGRAPHERS (GRADE C & GRADE D) EXAMINATION-2013

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

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

Please read instruction in the Notice of the Examination/Annexure-II 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)

6.

Vx BE iJ / Date of Birth

nx / Day

/Year

cx /Month

8. /Nationality
(J 1-i AB 2-+x)
(Write 1-Indian & 2 - Others)

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

10. gh / Category
(J 9-+x,1 +V,2 +VV AB 6-+{B)
(Write 9-General, 1-SC, 2-ST,
6-OBC)

10.1 +{ i{B xBE c ?

11.1 n c, BEb +BEi BE

12. BD + U] Sci c?

If Ex-serviceman

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

If yes, indicate code

Whether seeking Age relaxation ?

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

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

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

[ -C C,
-D D]

Preference for Post [ Write C for

Steno Grade-C & D for Steno Grade-D]
14.
(-1,
-2 )

Indicate medium for Skill Test

(English-1, Hindi-2)

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

B {i il/Date of Discharge
(nx/Day

13.{n BE |lBEi

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

[ /Year]

B +Bv / Length of Service

3 J
Write 3 in the box

9. BE / Fee
(J 1-BE BE Mix n 2- U] BE nB BE)
(Write 1-Fee paid & 2- Exemption claimed)

12.1 n c, BEb +BEi BE

cx/Month /year)
12.2

01.08.2013 BE + / Age as on 01.08.2013

If yes, indicate code

(n +BE BE JiBE BEb +BEi BE)

/ Years
cx / Months nx / Days
(Write two digit numeric code)
13.1 D (X,Y) BE |lBEi 13.2 -C // BE |lBEi
13.3 D (Gr-X) // BE |lBEi
Pref. of services/Deptt./ cadre for Steno Gr C
Pref. of services/Deptt. / cadre for Group X for
- X X, - Y Y
Steno Gr D
Preference for Group (X,Y)
1
2
1
2
3 4
1
2
3 4
5
6
for Steno Gr-D
write X for Group-X and Y for Group-Y
(Please refer to Para 13 of Notice)
(Please refer to Para 13 of Notice)
15. n vi BBEM c, i BD +{BE

|{BE BE +BBEi c ? (J 1-c, 2-xc)

If VH etc., whether scribe is required?
(Write 1-yes, 2-No)

17. FBE Mi Educational Qualification

BEb +BEi BE Indicate Code

15.1. n c, v +BEi BE
( +OV BE A 1, cxn BE A 2 J )
If yes, indicate medium,
(Write 1- English, 2-Hindi)

Subject Code

+BE BE |ii (%)

Percentage (%) of Marks

16. BD +{ +{JBE c?

( c -8)
Whether belong to Minority
Communities ? (If Yes, Write-8)

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_________________________________________________

___________________________________________________________
___________________________________________________________

BE BE BBh
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)

---------------------------------------------------------------------------------------------- PIN:
./ Mobile No. : .........................................................

/Email ID:.....

21.=nB BE ciF (BEB P] ci{ )

Signature of the Candidate in

the left Box
(Page 1 of 2)

22. / Declaration
..


Space for cancellation
stamp by post office
after affixing CRF stamp

24. ..

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)

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.

(i ) BE

BE
u
qBE
Vx
B
]
/
. .
BE]BE]
S{BEx
n bBEP
BE] cilx
Space

forcancellation
stamp

by post

office
after

affixing
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 at the time of skill test.
(vii)
/ /

For Candidate belonging Ex-Serviceman
I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of
examination and I have not availed employment in civil side under Central Government as Exserviceman.
(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:

( Do not Staple)
*
* Strike off this sentence if not applicable

Unsigned application will be rejected
(Page 2 of 2)