-/ANNEXURE-I

STAFF SELECTION COMMISSION

BE

A vBE (+) -

COMBINED HIGHER SECONDARY LEVEL (10+2) EXAMINATION-2011,

RECTT. OF LOWER DIVISION CLERK (LDC) & DATA ENTRY OPERATOR (DEO)
) Jx BE A x BE {x BE |M *

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

Please read instructions in the Notice of the Examination/Annexures 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

(J 1-j AB 2-{)
(Write 1-Female & 2- Male)

/Year

nx / Day cx /Month

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

7. M / Gender

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

3 J
Write 3 in the box

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)

13.1 ... (X,Y) BE |lBEi

14.

Indicate medium for Typing Test

(English-1, Hindi-2)
/ -

01.08.2011 BE + / Age as on 01.08.2011

/ Years

cx / Months

nx / Days

13.2 ... // BE |lBEi 13.3 ... (Gr-X) // BE |lBEi

Pref. of Services/Deptt./Cadre for DEO
1

Pref. of Services/Deptt./ Cadre for Group X for LDC

15. n vi BBEM c, i BD +{BE 15.1. n c, v +BEi BE

( +OV BE A 1, cxn BE A 2 J )
|{BE BE +BBEi c ? (J 1-c, 2-xc)
If yes, indicate medium,
If VH whether scribe is required?
(Write 1- English, 2-Hindi)
(Write 1-yes, 2-No)

(-1, -2 )

17.

(n +BE BE JiBE BEb +BEi BE)

(Write two digit numeric code)

Preference for Group (X,Y)

1
2
for LDC
Write X for Group-X and Y for Group-Y

Preference for Post [ Write L for

LDC and D & E for DEO]

12.2

If yes, indicate code

- X X, - Y Y

... D & E]

cx/Month /year)

12.1 n c, BEb +BEi BE

If yes, indicate code

[ ... L

(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

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

3 4

9 10

11

16. BD +{ +{JBE c?

(J 1-c AB 2-xc)
Whether belong to Minority
Communities ? (Write 1-Yes, 2-No)

BE |lBEi Preference of State/U.T.

10

18. FBE Mi Educational Qualification

BEb +BEi BE Indicate Code

11

12

13 14

15 16

17

Subject Code

18

19

20 21

22

23 24

+BE BE |ii (%)

Percentage (%) of Marks

v (+OV-1, cxn-2 B +x-3)

Medium ( English-1, Hindi-2, Others-3)

19. BE +xB BE BBh Details of work Experience / Govt. Service

l BE x
Name of the Organisation(s)

{nx

Designation

20. {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)

21. {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:.....

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

Signature of the Candidate in

the left Box (Only in running Hand)
(Page 1 of 2)

23.

..


Space for cancellation
stamp by post office
after affixing CRF
stamp

24. ..

Space for CRF Stamp

r 100.00 ..



( )

Paste here firmly CRF

Stamp of r 100.00
denomination and get
it cancelled from the
post office where
purchased.

( Do not Staple)

/Declaration

(i ) /

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 / ( )
/
/ /

*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 or will submit valid OBC Certificate at the time of Skill Test/Typing Test
as per the provision of the Notice.
(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.

=nB BE ciF (BEB P] ci{ )

Signature of candidate ( only in running hand)

lx/Place: ..
D

iJ/Date:
* n M x c i c <x BE] n *
* Strike off this sentence if not applicable

+ciFi +Bnx {j BE q BE n VM
Unsigned application will be rejected
(Page 2 of 2)