BYREIiISTERED

PDSTDNLY

HARYANA STAFF SELECTION COMMISSION

Bays No. 67-70, Sector-2, Panch kula
FOR OFFICE USE ONLY
CONTROL NO. ROLLNO. SCRUTINY
BY
I I I I I I
APPLICATION FORM

Treasury/PostOfficeName I I Try.Ch./I.P.O.
No. I I Date I I AmountI I
IMPORTANT INSTRUCTIONS
1. Please readinstructionsgivenin advertisement
carefully
beforefillingineachcolumn. Paste here
2. UseonlyBlack/Blue ballpento writeortickthebox. your latest
3. Piease tick 'Ves'as 521 and 'Not'as DO stamp size,
AdvertisementNo. Category No. Nameofthepost attested
I I I I I I photograph
1. CANDIDATE'S
NAMEincapallettersasgiveninclassXCertificate(inEnglish)
I I I I I I I I I I I I I I I I I I I I I I I I I I I
2. Father's
NameincapallettersasgiveninclassXCertificate
(inEnglish) I I
I I I I I I I I I I I I I I I I I I I I I I I I I I I Signature
of Candidate
3. Dateof Birth: Date Month Year
CD CD I I I I I
4. Ageasoneligibil date: Years Months Days
CD CD CD
5. Sex: Male0 Female 0
Gen. SC BCA BCB ESM DESM DFF Outstanding
sportsPer.
6. Category: c=J c=J c=J c=J c=J c:=::J c=J I I

7. Areyou domicileof Haryana: Yes I I No I I 8. National: IndianI I Other I I

9. Wre Nameandcompletemailingaddress,in block'ietters,wh blacksketchpenonly:-
Name:
Address : Pin Code
With Telephone No., if any I I I I I I I
10. EducationalQualifications:-
Educational Yearof Marks Total %age Division Nameof Board! Subjects
Qualifications Passing Obtained Marks University
10th (Matric)
10+2 (SeniorSecondary)
ITIN0cationai
Dioloma!DeGree
B.AJB.Sc./B.ComJB.E.
M.AJM.Sc./M.Com./M.E.

11. Anyotherhigherqualificationspecify

12. Experience: Years I I Months c=J Days I I

Nameof Organization: TotalSalary:Rs.
13. Visibleidentification
markonthebodyofthecandidate
14. Declaration:I herebydeclare
that:-
1. Allstatements madeinthisapplication
formaretrue,complete andcorrectto thebestofmyknowledge andbelief.Intheeventof anyinformation
beingfoundfalseorincorrect,orineligibil beingdetected
beforeoraftertheinterview/appointmenVselection.
mycandidature maybecancelled and
actioncanbetakenagainst me.
2. I havereadtheprovisions inadvertisement oftheCommission carefully
andIherebyundertaketo abidebythem.I fulfillallthecondionsofeligibil
regarding agelims, educational
qualifications
etc.prescribed
intheadvertisementandotherrelevantrulesandinstructions. .
3. I haveneverbeenconvictedby CriminalCourt.
Place: SIGNATURE
OFTHECANDIDATE
Date: (unsignedapplicationwill be rejected)