ONLY ONLINE APPLICATION WILL BE ACCEPTED.

FORM IS INDICATIVE
-/ANNEXURE-I
t-t -ttt -tt-t tttt t STAFF SELECTION COMMISSION
JUNIOR ENGINEERING(CIVIL/MECHANICAL/ELECTRICAL AND QUANTITY SURVEYING AND
CONTRACT) EXAMINATION 2013
tttt tt+tt t -tt t`ct -t t` t t-tztt ft-t-t t`ttt`ttt tt ttttt-tt ttt ta -t ttt t ( ) -t t`-tt-t t t`-t -tt-t tt tt-t t -t tt rtttt t
Please read instructions in the Notice of the Examination/Annexure-II carefully. Use Blue or Black ball pen to write in the box ( ( )

1. tt+tt t-r tt -tt-t f Name of the Examination Centre 2. t-r tt f Center Code

3. --tt tt tt t t -tt-t (tttt -t ) -tt`ct-tzt-t rt-ttt t-t -t t` t -tt-t t t-t tt t t+tt -t t`-tt -tt-t t t`t-rt t tttt t tt-t t ttt t tt tt-tt ut
Candidates Full Name (in English). Write in Capital Letters exactly as in Matriculation Certificate. Leave a box blank between any two parts of the name.


4. t`t-tt tt -tt-t (tttt t t t+tt -t t`-tt ) f Fathers Name (Write in Capital Letters in English)


5. -tt-tt tt -tt-t (t ttt t t t+tt -t t`-tt ) / Mothers Name (Write in Capital Letters in English)

6. t--t tt -tttt / Date of Birth

t`-t / Day -trt-tt /Month tt /Year
7. t-tt / Gender
(t`-tt 1--tt t z-tt)
(Write 1-Female & 2- Male)
8. tc tt-tt /Nationality
(t`-tt 1-tt-tt t t z-t-t)
(Write 1-Indian & 2 - Others)
9. zt-t / Fee
(t`-tt 1-zt-t tt tt-tt-t t z- u c tt ttt t`ttt)
(Write 1-Fee paid & 2- Exemption claimed)
10. ~t tt / Category
(t`-tt a-t-tt,1 ttt,z tttt t
e-tt`tt)
(Write 9-General, 1-SC, 2-ST,
6-OBC)
10.1 t tt ttt t-ttt tt`-tt r ?
Whether Ex-serviceman
(t`-tt s-t-ttt t t`-tt)
(Write 3- Ex-Serviceman)
10.3. t-ttt t t`-tt t t`-t For Ex-Serviceman
ttt ttt`t / Length of Service [tt /Year]
ttt t-ttt-t t`-tt`t/Date of Discharge
(t`-t/Day -trt-ttfMonth tt /year)

11. t tt ttt ztttt`t t`tt-ttt r
Whether PH ?
(t`-tt 1-rt t z--trt)
(Wrire 1-Yes, 2-No)
11.1 tt` rt, tt
tt`t-t t
If yes, indicate code
(t`-tt -t.t`t., s-~t.t`t., z- . t`t.)
(Write 4-OH, 5-HH,7-VH )
12. t tt ttt tt-tt -t uc -ttr-t r?
Whether seeking Age relaxation ?
(t`-tt 1-rt t z--trt) (Write -1-Yes, 2-No)
12.1 tt` rt, tt t t`t-t t
If yes, indicate code
(t ttt tt ttt--tt tt t t`t-t t)
(Write two digit numeric code)
12.2 (01.01.2013) tt ttt
Age as on (01.01.2013)

tt f Years -trt-t / Months t`-t / Days
13 Preference for Posts:
1 2 3 4 5 6 7 8 9 10 11



Please see para 14(A) of notice of the examination
14 Preference for States/UTs
1 2 3 4 5 6 7 8 9 10 11 12 13 14

15 16 17 18 19 20 21 22 23 24 25 26 27 28

Please see para14(B) of notice of the examination.
15. t tt ttt t-tttt r ?
(t`-tt s- rt )
Whether belong to Minority Communities
as per Govt. Orders? (Write 8, if yes.
Otherwise leave it blank)
16 Subject for General Engineering,Paper-I&Paper-II(Write A for Civil & Structural B for
Electrical & C for Mechanical)

16.1. tt` rt, -ttt-t t t`t-t t ( tttt t t`-t 1, t`r-t t t`-t z t`-tt )
If yes, indicate medium, ( Write 1- English, 2-Hindi)
18. ztt`+tt ttt-tt Educational Qualification
tt tt`t-t t Indicate Code


See Annexure-VIII of the Notice
t`t tt tt
Subject Code
ttt tt rtt`-tzt-t (%)
Percentage (%) of Marks




-ttt-t (tttt -1, t`r-t -z t t-t-s)
Medium ( English-1, Hindi-2, Others-3)






19. ttt t-ttt tt t`ttt Details of work Experience / Govt. Service rendered
t tt tt -tt-t
Name of the Organisation(s)
t-tt-t
Designation
ttt tt t`ttt
Nature of the Duty(ies)
ttt tt t-tt`t / Period of Service
t /From -tt / To


zet-tt: tt-t -tt-t tt`r-t t-t ttrt tt tt t-tt t ttt t t t+tt -t tt t`r-t -t -tt-t tt
tt-t tt-t t-t t t`-tt
Address: Write your complete Communication Address including your
Name in English Capital Letters or Hindi with Blue or Black Ball Pen.











zs.--tttt t r-tt+t (tt-t tttc r-tt`-tt`t -t)
Signature of the Candidate in the
above Box (Only in running Hand)




















Page 1 of 2








ii-i
Name___________________________________________________
-iii Address_____________________________________________
_______________________________________________________
_________________________________________________________
________________________________________________________
i`-ii PIN:
-ii ii;i i .; Mobile No. : .........................................................

Email ID: .
21. ttct ttt
+ :i-ii x s :i-ii ~iiii ii
tii ti -i iiii iii -iiiii-i
iti ii .i :i i`i-iiii
(:-ii i i -iii ii
:iiii` -ii i iii )
Photograph
Paste here firmly your recent
photograph
(4 c.m.X 5c.m)
(Do not staple. Do not get the
Photograph attested)
22. ~iisi-ii i (iii iiiiii .iiii ti )
Roll Number ( for Office use only)











10.2 If, ExS, whether
seeking reservation?

(Write Y-Yes, N-No)





22. ttttt fDeclaration





























(i ) -ii ;:i iii i i`i ii; ~ii ~iiii -i-i iti iii t -ii it -iii-i t i`i ii` -i ;:i i`ii-i ii iii iii;iii t ii
~iiiii ii -ii ~iiii :i:ii ii -i ~i:iiii i i`ii iiii
I have not submitted any other application for this examination. I amaware that if I contravene this
rule, my application will be rejected summarily by the Commission.
(ii) -ii i`iii-i -i i i; iii ii iii-iii -i. i`iii t ~ii -i iii iii -iiii ii ii iii ii;ii t
I have read the provisions in the Notice of the examination carefully and hereby undertake to abide by
them.
(iii) -i it ii iiiii iii;iii t i`i -i ;:i -iiii -i .iii i i`i i`iii i`i ~iii :ii-ii, ii`ii iiiii ~iii` :i iii -ii-iii ii
:iii iii ii -ii iii;iii t -i it ii ii iii iii;iii t i`i -i ;:i -iiii
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational
qualifications etc., prescribed for admission to the examination. I also declare that I shall not make
more than three attempts for the post of Assistant in CSS.
(iv) -i it ii ii iii iii;iii t i`i -ii ~iiiii i-iiii iii ~iiiii;:ii iii :iii ~iiiii ii i`i:ii ii -iiii -i ii :i
iti iii iii t iii -ii i`i:ii ii i`ii`i iiiiii ii iii ii i iii iti -iiii iii t | |, ~|| ||||| |.||/ |.|| , |`|
|| -|||| -||| -| |~|| ~|| |||-.| -|,| |`||| ||| , |||| ,||| -|,| ||| , |||| ||`|||| | ||-| || -||| -|||.| -|,| ||
| ,
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 criminal case is pending against me. Further declare that I have
never been dismissed or removed fromGovt. Service or my service been terminated during probation.
(v) * ~iii :ii-ii -i iiti iii is :iii i ~i:ii`ii i-iiii i i`i
-i it ii iii iii;iii t i`i -i i is :iii ii i ~i:ii`ii i-i iii t i i`iii`-ii ~iiii -i s ii ii :iii ii
:iiiiii ~iii`i i:ii ii -iiii iii`:i -i i`iii i`i t,
* For Central Govt. Civilian Employee seeking age relaxation.
I declare that I ama Central Govt. Civilian Employee and completed 3 years regular service or regular
length of service stipulated in the Notice of the examination.
(vi) * ~ii i`-ii ii :i :ii i`ii ~iiii i i`i
-i it ii iiiii iii;iii t i`i -i :i :i-iii :i :ii i`ii t i` i:i iii -ii i .ii`iii i`iiii i i`iii 8.9.1993 i
ii. ii. :i. ssc:z;zz;s :ii. (:i:iii) -i i`ii`ti ~iiii i ~ii:ii iii :iii ii :iii~ii -i ~iiii i .iiiii ti
i`-ii ii -iiii iii t it ii iiiii ii iiii t i`i -i iii :iii, iii-ii i .ii`iii i`iiii i i`ii`ii :iiiiii ii i`i
iii`:i -i ii`ii t, :ii iti -iiii iiiiii ii-ii :i. iii-i s -i iii`ii iiiiii;iii ( sii-iiii) :i :ii i`ii
iti t -i it ii iiiii iii;iii t i`i -i -ii:i -iiii iii`:i -i i`iiii`i .ii-i -i ~ii i`-ii ii ii .i-iii -i-i t
*For Candidate belonging to OBC.
I declare that I belong to the community which is recognized as an other 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 MemorandumNo.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 OBC Certificate in the prescribed format as stipulated in the Notice of the
examination.
(vii) ii-ii :i i`iii i i`i
-i iiiii iii;iii t i`i -i -iiii i`iii-i i ~ii:ii ii-ii :i i`ii :ii i`ii -ii-iii ii :iii iii ii -ii iii;iii t
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 i ii iiiii iii;iii t i`i ;:i ~iiii -i-i -i i` i :iii i`iii -ii ~ii`iii-i iiiiii ~ii i`iii:i i ~ii:ii
:ii, -ii i :iti t -i :i-iiii;:i-iiii t i`i -iiii :i -iti ii ii -i ii; ii :iiii -ii; t;;ii ii ~i:ii -ii; iii
-i ii ~i-ii-iii ii -iii iii -i -ii ~iiiiii;i`iiiii i`i:i ii ii :iiii t
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.


:iii;Place: ..
D D M M Y Y
iiii;Date:

* ii` iii i ti ii it ii; i ii
* Strike off this sentence if not applicable
--iiii i t:iii (iii i:ii t:ii`ii`-i -i)
Signature of candidate ( only in running hand)


~it:iiii`i ~iiii -i-i ii i i`ii iiiii
Unsigned application will be rejected

(Page 2 of 2)