Registration ID :

Haryana Staff Selection

Commission
431135

1. Applicant's Name: DEEPAK

2. Father's Name: MOHAN LAL

3. Mother's Name: SAROJ

4. Gender: MALE

5. Date of Birth: 04/04/2001

6. Marital Status: UNMARRIED

7. Nationality: INDIAN

8. Visible Indentity Mark on body: NO

9. If any FIR is lodged/Pending NO

against the applicant?:

10. Address & Contact Details: HOUSE NO.- 788/ STREET NO.- 5/ LAND
MARK- MELA GROUND WARD NO 13
SIRSA/ PINCODE- 125055, WARD 12,
SIRSA MC, SIRSA, HARYANA, 125055

11. Mobile No : 7015107759

12. Email Id : meghwaldeepak833@gmail.com

Reservation Details

13. Category: SC

14. Benchmark Disability : NO

15. EWS : NOT APPLICABLE

16. Ex-Serviceman : NO

17. Interested Job Category : GROUP D

18. Eligible Sports Person (ESP): NO

19. Are you domicile of Haryana State: YES

20. Is DESM (Ex-Servicemen Dependent)?: NA

21. Did you passed/studying Hindi/Sanskrit in class 10th or YES

above?:

22. Payment Detail: FEE PAID ON 30/03/2021

23. Would you be availing the benefit of reservation policy of NA

Goverment of Haryana in recruitment to Group C and Group D
posts?:

Qualifying Examination Details

Education Board / Result Roll No. Marksheet Grading Mark Total Percentage
University Type No. System Obtained Marks

Class10th Haryana Board Pass 2017443152 125241 Non 426 500 85

of School CGPA
Education

Class12th Haryana Board Pass 3019448936 112285 Non 430 500 86

of School CGPA
Education
 Socio Economic Criteria

1. Any person from among the applicant's father, mother, spouse, NO

brother and son is/ was or has been a regular employee in any
department/ Board/ Corporation/ Company/ Statutory Body/
Commission/ Authority of Government of Haryana or any other
state Government or Government of India:

2. Is Applicant a Widow? : NO

3. Is father of candidate is deceased? : NO

4. If the applicant belongs to such a denotified tribe(Vimukt Jatis NO

and Tapriwas Jatis) or Nomadic tribe of Haryana which is nether a
Scheduled Caste nor a Backward Class. :

5. Age relaxation due to experience: NO

Experience Details

Declaration by Candidate

1. I have not sent any other application for this recruitment. I know if I violate this rule. My application will
be cancelled by the Staff Selection Commission.

2. I have carefully read all the conditions given in the release and hereby I am eligible for this post and abide
by them I promise to.

3. I also declare that I fulfils all the condition related age limits, educational qualifications and finds which
are prescribed for this recruitment.

4. For Ex-Servicemen, I announce that I fulfils all the conditions of Ex-Serviceman related eligibility as per
advertisement.

5. I also declare that till date I have not been prevented from appearing in any examination / experiential
course by any agency / selection committee of the State of Haryana and have not been convicted by any
legal court.

6. For the candidates belonging to the Other Backward Classes, I declare that I belong to the community
which has been considered as a backward class for the purpose of reservation in services by the State
Government, as per the State Government orders. It is also announced that the State Government, by the
various amendments mentioned in the notice are not related to the mentioned individuals / categories. I
also declare that I have a certificate of OBC.

7. I also declare that I have applied only in one reserved category prescribed by the Government of Haryana.

8. I hereby declare that all the details given in this application form are true, complete and correct as per my
maximum information and belief. I understand / understand that my candidature / appointment can be
cancelled if any information is found to be hidden / false or untrue or if ineligibility is detected.

Place : Sirsa

Date : 08/06/2023

Candidate Signature : ------------