Registration ID :

Haryana Staff Selection

Commission 1619806

1. Applicant's Name: ANIL KUMAR

2. Father's Name: JAG RAM

3. Mother's Name: USHA RANI

4. Gender: MALE

5. Date of Birth: 07/10/1989

6. Marital Status: MARRIED

7. Nationality: INDIAN

8. Visible Indentity Mark on body: CUT MARK NEAR LEFT EYE

9. If any FIR is lodged/Pending NO

against the applicant?:

10. Address & Contact Details:
HOUSE NO.- 142/ STREET NO.- MAIN
STREET/ LAND MARK- HAMIDPUR/
PINCODE- 136156, HAMIDPUR,
BABAIN BL, KURUKSHETRA,
HARYANA, 136156

11. Mobile No : 8930308011

12. Email Id : anil.sa.0908@gmail.com

Reservation Details

13. Category: BC (B)

14. Benchmark Disability : NO

15. EWS : NO

16. Ex-Serviceman : NO

17. Interested Job Category : GROUP C

18. Eligible Sports Person (ESP): NO

19. Are you domicile of Haryana State: YES

20. Is DESM (Ex-Servicemen Dependent)?: NO

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

above?:

22. Payment Detail: FEE PAID ON 10/07/2022

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

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

Qualifying Examination Details

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

Class10th Haryana Board of Pass 600785 117327 Non 415 600 69.17
School Education CGPA

Graduation Kurukshetra Pass 7310331 0703801 Non 4405 6200 71.04

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

Diploma Haryana State Board Pass 040109008 038256 Non 4232 6900 61.33
of Technical CGPA
Education (HSBTE)
 Socio Economic Criteria

1. Any person from among the applicant's father, mother, YES

spouse, 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 NO

Jatis 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 : Babain

Date : 10/07/2022
Candidate Signature : ------------