Application Form

Applicant Copy (To be retained by the applicant)

Applicantion Sequnece
AM92002085
Number/User ID:
User Password: 393699
Personal Details
Advertisement Number :
4191
Advertisement Date : 24th December 2016
Post Applied : Amin

Nationality : Indian
Applicant Full Name : Mr DEEPAK KUMAR PRADHAN
Applicant Father's Name Mr
CHAKRADHAR PRADHAN
Applicant Mother's Name Mrs BASANTI PRADHAN
:
Applicant Husband's Mr
Name :
Other Personal Details
Gender : Male
Mobile Number : 7540950599
Email Address : deepakpradhan1996.95@gmail.com
Current Address:(All Communication to the candidate from OSSC is to be made in this address)
House No., Street/Lane, At/Po-Tinkbir
Village , Post Office,
Police Stn, etc :
State/U.T. : ODISHA
Tehsil/City : Reamal
District : Deogarh
District Other:
Pin code : 768109
Permanent Address
House No., Street/Lane, At/Po-Tinkbir
Village , Post Office,
Police Stn, etc :
State/U.T. : ODISHA
Tehsil/City : Reamal
District : Deogarh
District Other:
Pin code : 768109
Exam City
Choice of district/city for appearing in the examination Rourkela
Other Details
Whether passed minimum
Yes
Seventh class exam. in Odia :
Applicant Age Details
Date of Birth : 10/Jun/1996
Age as on 01.01.2016 : 19 Years 6 Months 22 Days
Category Details
Category Claimed : Scheduled Tribe - ST
Date Of Issue SEBC
Certificate :
Special Category
Physically Challenged : No
Type of Physical
disability:
Whether Ex-
No
Serviceman :
Have you ever Availed
the benefits of Ex-
Service Man for re-
employment in Govt
Service :
Served in :
No. of Years , Months & Years Months Days
Days served :
Date / Likely date of
Discharge :
Whether holder of Sports Person Certificate No
ID card no. issued by
Director of Sports :

In Service Details
In Service (Odisha Govt.
Contractual) : No
From Date :
To Date :
Total Years & Months Years Months Days
Of Experience :
Are you employed under
:
Name of the
Organisation :
Name Of the Post :
Work Experience
Do you have minimum 5 years of actual service in rank of amin/equivalent or higher grade
No
there to in settlement or consolidation Organization
Sl. No Organisation Name From Date To Date No. of years of Service
.
1.

2.

3.

4.

5.

Total Experience :
Have you passed All India Trade Test in Surveyor Trade conducted by National Council of
Training in Vocational Trades?
No

10th Standard Details

10th Standard Roll
Number As Mentioned 02ME097
in the Certificate
10th Standard Passed
Exam Type Annual
Year Of Passing 2011
Board / University BSE,Odisha
10th Standard Other
Board BSE,Odisha
CGPA/Percentage Percentage
Division First
Total Marks 600
Marks Obtained 410
Percentage Obtained 68.33
Exam 10 + 2/Equivalent Details
Stream Science
Other Stream
Board / University CHSE,Odisha
Other Board / University
CGPA/Percentage Percentage
Year Of Passing 2013
Division First
Total Marks 600
Marks Obtained 380
Percentage Obtained 63.33
Post Specific Requirement
Have you done a course in basic computer skill from any recognized institution Yes
Name Of the Institution NICET
Name Of the Course DCA
Date of the Course
30/11/2013
Completion
Other Name Of the
Course
Treasury Challan Details:
Treasury Challan
Number :
Treasury Challan Date :
Name Of Treasury:
Amount: 0
 Application Form
OSSC Copy
Applicantion Sequence
Number/User ID: AM92002085

Personal Details
Advertisement Number :
4191

Advertisement Date : 24th December 2016

Post Name: Amin

Nationality : Indian
Applicant Full Name : Mr DEEPAK KUMAR PRADHAN
Applicant Father's Name Mr CHAKRADHAR PRADHAN
Applicant Mother's Name Mrs BASANTI PRADHAN
Applicant Husband's Mr
Name :
Other Personal Details
Gender : Male
Mobile Number : 7540950599
Email Address : deepakpradhan1996.95@gmail.com
Current Address:(All Communication to the candidate from OSSC is to be made in this address)
House No., Street/Lane, At/Po-Tinkbir
Village , Post Office,
Police Stn, etc :
State/U.T. : ODISHA
Tehsil/City : Reamal
District : Deogarh
District Other:
Pin code : 768109
Permanent Address
House No., Street/Lane, At/Po-Tinkbir
Village , Post Office,
Police Stn, etc :
State/U.T. : ODISHA
Tehsil/City : Reamal
District : Deogarh
District Other:
Pin code : 768109
Exam City
Choice of district/city for appearing in the examination Rourkela
Other Details
Whether passed minimum Yes
Seventh class exam. in Odia :
Applicant Age Details
Date of Birth : 10/Jun/1996
Age as on 01.01.2016 : 19 Years 6 Months 22 Days
Category Details
Category Claimed : Scheduled Tribe - ST
Date Of Issue SEBC
Certificate :
Special Category
Physically Challenged : No
Type of Physical
disability:
Whether Ex-Serviceman No
:
Have you ever Availed
the benefits of Ex-
Service Man for re-
employment in Govt
Service :
Served in :
No. of Years , Months & Years Months Days
Days served :
Date / Likely date of
Discharge :
Whether holder of Sports Person Certificate No
ID card no. issued by
Director of Sports :

In Service Details
In Service (Odisha Govt.
Contractual) : No
From Date :
To Date :
Total Years & Months Years Months Days
Of Experience :
Are you employed under
:
Name of the
Organisation :
Name Of the Post :
Work Experience
Do you have minimum 5 years of actual service in rank of amin/equivalent or higher grade
there to in settlement or consolidation Organization
No

Sl. No Organisation Name From Date To Date No. of years of Service

.
1.

2.

3.

4.

5.

Total Experience :
Have you passed All India Trade Test in Surveyor Trade conducted by National Council of
Training in Vocational Trades? No
10th Standard Details
10th Standard Roll
Number As Mentioned 02ME097
in the Certificate
10th Standard Passed
Exam Type Annual
Year Of Passing 2011
Board / University BSE,Odisha
10th Standard Other
Board BSE,Odisha
CGPA/Percentage Percentage
Division First
Total Marks 600
Marks Obtained 410
Percentage Obtained 68.33
Exam 10 + 2/Equivalent Details
Stream Science
Other Stream
Board / University CHSE,Odisha
Other Board / University
CGPA/Percentage Percentage
Year Of Passing 2013
Division First
Total Marks 600
Marks Obtained 380
Percentage Obtained 63.33
Post Specific Requirement
Have you done a course in basic computer skill from any recognized institution Yes
Name Of the Institution NICET
Name Of the Course DCA
Date of the Course
30/11/2013
Completion
Other Name Of the
Course
Treasury Challan Details:
Treasury Challan
Number :
Treasury Challan Date :
Name Of Treasury:
Amount: 0
Declaration
I __________________________ Son/ Daughter of Shri _________________________
Age___________ Year__________
resident of ________________ District ________________ hereby declare that the information
given above and in the enclosed
documents is true to the best of my knowledge and belief and nothing has been concealed therein.
I am well aware of the fact that
if the information given by me is proved false/ not true, I will have to face the punishment as per
the law. Also, all the benefits
availed by me shall be summarily withdrawn.

Signature should not exceed the box provided

Date:

Place:

Full Signature of the Applicant (Ink Signed)

Sender By Post
From

Name: DEEPAK KUMAR PRADHAN To,

Fathers Name: CHAKRADHAR PRADHAN The Secretary,
House No., : At/Po-Tinkbir Odisha Staff Selection Commission,
Street/Lane, Barrack No.1,
Village , Unit No.V,
Post Office, Bhubaneswar-751054.
Police Stn

Tel: 06742392233
Fax: 06742391153
City/Tehsil: Reamal
District: Deogarh
Other District:
Pincode: 768109