Registration ID :

Haryana Staff Selection

Commission 115637

1. Applicant's Name: SANDEEP

2. Father's Name: SATPAL

3. Mother's Name: NARESH RANI

4. Gender: MALE

5. Date of Birth: 18/02/1996

6. Marital Status: UNMARRIED

7. Nationality: INDIAN

8. Visible Indentity Mark on body: A MOLE ON FACE

9. If any FIR is lodged/Pending NO

against the applicant?:
10. Address & Contact Details:
HOUSE NO.- VPO UCHANA/ STREET
NO.- WARD NO 2/ LAND MARK- VPO
UCHANA KALAN/ PINCODE- 126115,
WARD 2, UCHANA MC, JIND, HARYANA,
126115

11. Mobile No : 8570024660

12. Email Id : sheokand686@gmail.com

Reservation Details

13. Category: GEN

14. Benchmark Disability : NO

15. EWS : NO

16. Ex-Serviceman : NO

17. Interested Job Category : GROUP C & 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 19/03/2021

Qualifying Examination Details

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

Class10th Haryana Board of Pass 2210547655 AM- Non 483 500 96.6
School Education 114013 CGPA

Class12th Haryana Board of Pass 3212140402 AN- Non 444 500 88.8
School Education 067741 CGPA

Graduation Kurukshetra Pass 3376228 1032502 Non 2072 2900 71.45

University, CGPA
Kurukshetra- 136
119, Haryana. (State
University)
 Socio Economic Criteria

1. Any person from among the applicant's father, mother, spouse, YES
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 : UCHANA MANDI, JIND

Date : 22/05/2022

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