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‚ã¶ãìºãâ£ã-ý/ANNEXURE-I

·t·-t-ttºt -tªt-t ÷ttªtt¹t STAFF SELECTION COMMISSION
ªtªt·t-t ª-tt-t·t· ª-tº ·tºt+tt-ze1z
COMBINED GRADUATE LEVEL EXAMINATION-2012
·t· ·tªtt ·tºt +tt ·t· -ttt` cªt -t t` ¤¢ ¹t¢ ÷t-t ¤zttfªt -t¹-t t` ·t·tºt` ºt·t·t ·t·t ªtt·t·tt-tt ·t ·t ·t· ·ta -t ¡ ·tt ·tªt ( ) -t t` -t×t-t ·t· t` -t¢ -tt -t ªtt ·t·t-t ·t-t ·t·t rtªtt¹t ·t·º ¡
Please read instructions in the Notice of the Examination/Annexure-II carefully. Use Blue or Black ball pen to write in the box ( ( )

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

3. ¤--tt ¤·ttº ·t·t ·tºt -tt-t (÷t ¡t¢tt -t) -t t` c¸ ·t ·-tzt-t rt-ttºt ·t-t -t t` ¤¢ ¹t¢ -tt-t ·t· ÷t-t ªttº ·t× ÷t+tºt -t t` -t×t ¡ -tt-t ·t· t` ·t·-rt ¤t ªtt¹tt ·t· ·tt-t ¢·t· ·tt ·tªt ·t·t ×tt-tt ut× ¤ ¡
Candidate’s 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 ·t·t -tt-t (÷t ¡t¢tt ·t· ·t× ÷t+tºt -t t` -t×t) f Father’s Name (Write in Capital Letters in English)


5. -tt-tt ·t·t -tt-t (÷t ¡t¢tt ·t· ·t× ÷t+tºt -t t` -t×t) / Mother’s Name (Write in Capital Letters in English)

6. ¢t--t ·t·t -ttºt ×t / Date of Birth

t` ¤-t / Day -trt -tt /Month ·t·t /Year

7. t¨ -t¹t / Gender
(t` -t×t 1-ª-tt ¢·t z-·t ÷·t)
(Write 1-Female & 2- Male)
8. ºt·c¸ t ªt-tt /Nationality
(t` -t×t 1-ªttº-tt ªt ¢·t z-÷t-ªt)
(Write 1-Indian & 2 - Others)
9. zt -·t· / Fee
(t` -t×t 1-zt -·t· ·t·t ªt ¹t-tt-t ¤ªt z- u c ·t·t ¤t·tt t` ·t·ªtt)
(Write 1-Fee paid & 2- Exemption claimed)
10. ~tºtt / Category
(t` -t×t a-÷t-tt,1 ÷t¢tt,z ÷t¢t¢tt ¢·t e-÷tt` ·t·t)
(Write 9-General, 1-SC, 2-ST,
6-OBC)

10.1 ·t ªtt ÷tt·t ªt -t·t ·t ªt t` -t·t· r ?
Whether Ex-serviceman ?
(t` -t×t s-ªt -t·t ·t ªt t` -t·t·)
(Write 3- Ex-Serviceman)
10.2. ªt -t·t ·t ªt t` -t·t· ·t· t` -t¢ For Ex-Serviceman
ªt·tt ÷t·tt` ·t / Length of Service [·t·t /Year]
ªt·tt ªt-ttt ·-t t` -tt` ªt/Date of Discharge
(t` ¤-t/Day -trt -ttfMonth ·t·t /year)


11. ·tªtt ÷tt·t zttºt t` º·t· t` ·t·t·-tt ¹t r ?
Whether PH ?
(t` -t×t 1-rt ¢·t z--trt )
(Wrire 1-Yes, 2-No)
11.1 ªtt` ¤ rt , ·t·t÷ ÷t t` ·t·-t ·t·º
If yes, indicate code
(t` -t×t «-÷t.t` ·t., s-~t.t` ·t., z- ¡. t` ·t.)
(Write 4-OH, 5-HH,7-VH )
12. ·tªtt ÷ttªt ªtt -tt -t u c -ttr-t r ?
Whether seeking Age relaxation ?
(t` -t×t 1-rt ¢·t z--trt ) (Write -1-Yes, 2-No)
12.1 ªtt` ¤ rt , ·t·t÷ ÷t t` ·t·-t ·t·º
If yes, indicate code
(¤t ÷t ·t·t ·t·t ªt תtt--t·t· ·t·t÷ ÷t t` ·t·-t ·t·º )
(Write two digit numeric code)
12.2 (01.01.2012) ·t·t ÷ttªt
Age as on (01.01.2012)

·t·t f Years -trt -t / Months t` ¤-t / Days
13 Preference for Posts:
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



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

15. ·tªtt ÷tt·t ÷t-·tªt תt·t· r ?
(t` -t×t s- यदि rt अनयथा खाली छोडे )
Whether belong to Minority Communities
as per Govt. Orders? (Write 8, if yes.
Otherwise leave it blank)
16. ªtt` ¤ ¡t` ·c ·ttt`·t-t t` ·t·t·-tt ¹t r , -tt ·tªtt ÷tt·t·t·t rtt` -tt` ·t·t· ·t·t ÷tt·tzªt·t·-tt r ? (t` -t×t 1-rt , z--trt )
If VH, whether scribe is required ? (Write 1-yes, 2-No)
16.1. ªtt` ¤ rt , -tt·ªt-t ÷t t` ·t·-t ·t·º ( ÷t ¡t¢tt ·t· t`-t¢ 1, t` r-¤t ·t· t` -t¢ z t` -t×t )
If yes, indicate medium, ( Write 1- English, 2-Hindi)
17. zt t` +t·t· ªtt¹ªt-tt Educational Qualification
·t·t÷ ÷t t` ·t·-t ·t·º Indicate Code


See Annexure-X of the Notice
t` ·t·tªt ·t·t÷
Subject Code
÷t ·t·t ·t·t rtt` -tzt-t (%)
Percentage (%) of Marks




-tt·ªt-t (÷t ¡t¢tt -1, t` r-¤t -z ·t ÷t-ªt-s)
Medium ( English-1, Hindi-2, Others-3)






18. ·t·tªt ÷t-tªt·t ·t·t t`·t·tººt Details of work Experience / Govt. Service rendered
ªt ªªtt ·t·t -tt-t
Name of the Organisation(s)
·t¤-tt-t
Designation
·t·tªt ·t·t t` ·t·tººt
Nature of the Duty(ies)
·t·tªt ·t·t ÷t-tt` ·t / Period of Service
ªt /From -t·t· / To




19. ·t-tt: ÷t·t-t -tt-t ªtt` r-t ·t-t ·ªt·trtº ·t·t ·t ºt ·t-tt ÷t ¡t¢tt ·t· ·t× ÷t+tºt -t ªtt t` r-¤t -t -tt -t
ªtt ·t·t-t ·tt -t ·t-t ªt t` -t×t ¡
Address: Write your complete Communication Address including your
Name in English Capital Letters or Hindi with Blue or Black Ball Pen.











21. ¤--tt ¤·ttº ·t· rª-tt+tº (·t··t-t ·tªtt c rª-tt` -tt` ·t -t)
Signature of the Candidate in the
above Box (Only in running Hand)




















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

Email ID:…………………………………………………….
20. ·t·tct¡tt·t·
+ :i -ii x s :i -ii ~ii·i·iº ·i·i
ti·i ti -i ªii·ii ·i·ii -i·i ·i ·ii-i·
·iti ·i ·i· . ·i :i i`·i-i·i·i·i
(:· -i·i ·i ·i·º -i·i ·i ·i·i
:i··iii`-i·i ·i ·i·º·ii¸ )
Photograph
Paste here firmly your recent
photograph
(4 c.m.X 5c.m)
(Do not staple. Do not get the
Photograph attested)
~i·isi·-ii ·i· (·i· ·i·i ·i·i·ii ·i·i .i·ii ·i t ·i )
Roll Number ( for Office use only)



















22. ·tt·tºtt fDeclaration































zs. ·i· . ·i. ·i··i· i`··i·· ·i· i`·i¸
:ªii·i
Space for CRF Stamp
r 100.00 ·i·i ·i· . ·i.
·i··i· i`··i·· ·iti ·i·i· . ·i
:i i`·i-i·i·i¸ ·iªii ÷i·i··iº :i
º· ·i·ºi · ·iti :i ·it
ªiºi ·i ·i·ii t
(:·-i·i ·i ·i·º )

Paste here firmly CRF
Stamp of r 100.00
denomination and get
it cancelled from the
post office where
purchased.
( Do not Staple)
·i· . ·i. ·i ··i· i` ··i·· i` ·i-i·i·i·i
·i· ·ii· ÷i·i··iº ¡iºi º· i` ·i··i
·ii·i ·ii·i i` ··i·· t ·i :ªii·i
Space for cancellation
stamp by post office
after affixing CRF
stamp
(i ) -i ·i ;:i ·i·ii ·i· i` ·i¸ ·i·i ; ~ii º ~ii·i ··i -i-i ·iti ·i ·ii t -i ·i ·it -ii·i -i t i` ·i· ·ii` · -i ;:i i` ·i·i-i ·i·i ¬··i ·i·i ·i·º·ii;·i·º·ii t ·ii
~ii·ii ·i ¡iºi -i ºi ~ii·i ··i :iº:iºi ·ii º -iº ~i:·ii ·i··i ·i·º i` ··ii ·ii¸·ii
I have not submitted any other application for this examination. I am aware that if I contravene this
rule, my application will be rejected summarily by the Commission.
(ii) -i ·i i` ·i·ii -·i -i ·i ·i; ·i·ii ·i·i ··ii·i-i ·i ·i· -i. i` ·i·ii t ~ii º -i ¸·i· ¡iºi ¬·i·i·i -ii·i·i ·i·º·i ·i·i ·i·i·i · ·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 ·ii iºii ·i·º·ii;·i·º·ii t i` ·i· -i ;:i -iºi ·ii -i .i·i ·i ·i· i` ·i¸ i` ·i·ii i` º·i ~ii·i :ii -ii, ·i i` ·i·i· ·ii ··i·ii ~iii` · :i ·i ·ii -ii-i·ii ·i·i
:i·ii ·i·ii ·i·i -i ºi ·i·º·ii;·i·º·ii t -i ·it ·ii ·ii iºii ·i·º·ii;·i·º·ii t i` ·i· -i ;:i -iºi ·ii
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 iºii ·i·º·ii;·i·º·ii t i` ·i· -i ·i ~ii·i·i·i· ·i·-i ·iiºi ·i·i·i ~ii·ii ·i;:i ·i ·ii ·i· :i ·ii ~ii·ii ·i ¡iºi i` ·i·:ii ·ii -iºi ·ii -i ·i ··i :i
·iti ºi ·i·i ·i·ii t ·iªii -i ·i i` ·i·:ii ·ii i` ·ii` ·i ··ii·ii·i·i ¡iºi ·i··ii ·ii ·i iii ·iti -ii·ii ·i·ii t ·| ·|, ~|| ·||·|º|| ‡|Šª.||/ ‡|Šª.|| ,¸ |`‡|Š
·|ª| -|ª‡|Š|ª| -|·|| -| ‡|Š~|| ~|| ·|Œ||-.| -|,| |`‡|Š·|| ·|·|| , ‚|ª|·|| ,›|·|| -|,| ·|·|| , ‚|ª|·|| ·||`ª·||÷|| ‡|Š ·|ª|-| ·|ª| -|·|| -|·||·.| -|,| ‡|Š|
·|ƒ , ¡
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 from Govt. Service or my service been terminated during probation.
(v) * ~ii·i :ii -ii -i ·· ·iit·i ·ii·i ·i··s :iº·i·iº ·i· ~i:i i` ·i·i· ·i·-i ·iiºi ·i· i` ·i¸
-i ·it ·ii iºii ·i·º·ii;·i·º·ii t i` ·i· -i ¸·i· ·i··s :iº·i·iº ·i·i ¸·i· ~i:i i` ·i·i· ·i·-i ·iiºi t ¸·i i` ·i·ii` -i·i ~ii·iiº -iº s ·ii ·i·i :i ·ii ·ii
:i ·ii·i·i·i ~i·ii` ·i ·i :ii ·i·i -iºi ·ii ·ii i` ·:i -i i` ·i·ii i` º·i t ,
* For Central Govt. Civilian Employee seeking age relaxation.
I declare that I am a Central Govt. Civilian Employee and completed 3 years regular service or regular
length of service stipulated in the Notice of the examination.
(vi) * ~i··i i` -i··i ·i·i :i :i ·i i` ·i·i ~i··iªii ·i· i` ·i¸
-i ·it ·ii ·ii iºii ·i·º·ii;·i·º·ii t i` ·i· -i ¬:i :i-i ·i·i :i :i ·i i` ·i·i t i` ·i:i ·i·ii` -i·i· ¸·i .ii` ·i·iºi i` ·i·ii·i ·i· i` ··ii ·i· 8.9.1993 ·i·
·i·i. ·ii. :i . ssc:z;zz;¤s :ªii. (¸:i:ii ·i ) -i i` ·ii` t·i ~ii· ·ii ·i· ~i·i:iiº ·iiº·i :iº·i·iº ¡iºi :i ·ii~ii -i ~iiº·iºi ·i· .i·ii ·i·i t ·i
i` -i·÷i ·i·i -ii·ii ·i·ii t ·it ·ii ·ii iºii ·i·i ·ii·ii t i` ·i· -i ·iiº·i :iº·i·iº, ·i·ii` -i·i· ¸·i .ii` ·i·iºi i` ·i·ii·i ·i· i` ·ii` ·i··i :i ·ii ·i·ii ·ii i` ·i·
·ii i` ·:i -i ¬··i i` ªi·i t , ¬:i·i· ·it·i ¬-iºi ·i ·i ·i·i·ii ·i·i ·ii-i·i :i . ·i·i ·i-i s -i ¬i ··ii` ªi·i ··ii ·i ·i·ii ;·i·ii ( si·i -ii ·i ·iº) :i :i ·i i` ·i·i
·iti t -i ·it ·ii ·ii iºii ·i·º·ii;·i·º·ii t i` ·i· -i º -ii:i -iºi ·ii ·ii i` ·:i -i i` ·i·ii i` º·i .ii÷-i -i ~i··i i` -i·÷i ·i·i ·i·i .i-iiºi -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 Memorandum No.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) ·i ·i-i ·i :i i` ·i·i·i ·i· i` ·i¸
-i ·ii iºii ·i·º·ii;·i·º·ii t i` ·i· -i -iºi ·ii i` ·i·ii -·i ·i· ~i·i:iiº ·i ·i-i ·i :i i` ·i·i· :i ·i i` ·i·i -ii-i·ii ·i·i :i·ii ·i·ii ·i·i -i ºi ·i·º·ii;·i·º·ii 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· ¡iºi ·ii iºii ·i·º·ii;·i·º·ii t i` ·i· ;:i ~ii·i ··i -i-i -i i` ·¸ ·i¸ :i·ii i` ·i·iººi -i ºi ~ii` ·i·i··i-i ·ii·i·i·iºi ~ii º i` ·i··ii:i ·i· ~i·i:iiº
:i··i, -i ºi ¸·i :iti t -i :i-i·i·ii;:i-i·i·ii t i` ·i· -iºi ·ii :i -it·i ·ii ·ii· -i ·i·i ; ·ii :i ·i·ii ·-ii ; t ; ;·i ·i ·ii ~i:i··i -ii; ·ii·i
-iº ·ii ~i-ii-i·ii ·i·i -i·ii ·i·i·i -iº -i ºi ~i··ii` ªi·ii;i` ·i·i i ·i ·i i` ·iº:·i ·i·i ·ii :i·i··ii 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.


:ªii·i;Place: ………………………………..
D D M M Y Y
·iiºiªi;Date:

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


~it:·ii·ii`º·i ~ii·i ··i -i-i ·i·i º· ·i·º i`··ii ·ii·i·ii
Unsigned application will be rejected

(Page 2 of 2)



£É. (v) * +ÉɪÉÖ ºÉÉÒàÉÉ àÉå UÝ] SÉÉcxÉä BÉÉãÉä BÉEäxp ºÉ®BÉEÉ® BÉEä +ɺÉèÉÊxÉBÉE BÉEàÉÇSÉÉ®ÉÒ BÉEä ÉÊãÉA àÉé ªÉc PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE àÉé ABÉE BÉEäxp ºÉ®BÉEÉ® BÉEÉ ABÉE +ɺÉèÉÊxÉBÉE BÉEàÉÇSÉÉ®ÉÒ cÝÄ ABÉÆ ÉÊxɪÉÉÊàÉiÉ +ÉÉvÉÉ® {É® 3 BÉÞÉÇ BÉEÉÒ ºÉäBÉÉ ªÉÉ ºÉäBÉÉBÉEÉãÉ +ÉBÉÉÊvÉ VÉèºÉÉ BÉEÉÒ {É®ÉÒFÉÉ xÉÉäÉÊ]ºÉ àÉå ÉÊxÉvÉÉÇÉÊ®iÉ cè. of India DOPT OMs mentioned in the Notice.00 denomination and get it cancelled from the post office where purchased. of India for the purpose of reservation in services as per order contained in Deptt. Civilian Employee seeking age relaxation. I declare that I belong to the community which is recognized as an other backward class by the Govt. my candidature/appointment is liable to be cancelled. I understand that in the event of any information being found suppressed/false or incorrect or ineligibility being detected before or after the examination. ¶ÉÖãBÉE ÉÊ]BÉE] ÉÊSÉ{ÉBÉEÉxÉä BÉEä ¤ÉÉn bÉBÉEPÉ® uÉ®É ®q ÉÊBÉEªÉä VÉÉxÉä BÉÉãÉä ÉÊ]BÉE] cäiÉÖ ºlÉÉxÉ Space for cancellation stamp by post office after affixing CRF stamp 23. I also declare that I shall not make more than three attempts for the post of Assistant in CSS.00 BÉEÉ BÉEä. I declare that I am a Central Govt. BÉEÉÉÌàÉBÉE ABÉÆ |ÉÉʶÉFÉhÉ ÉÊBÉ£ÉÉMÉ BÉEä ÉÊBÉÉÊ£ÉxxÉ ºÉƶÉÉävÉxÉÉå VÉÉä ÉÊBÉE xÉÉäÉÊ]ºÉ àÉå =ããÉäÉÊJÉiÉ cè.9. =ààÉÉÒnBÉÉ® BÉEä cºiÉÉFÉ® (BÉEäBÉãÉ PɺÉÉÒ] cºiÉÉÊãÉÉÊ{É àÉå) Signature of candidate ( only in running hand) BÉEä. Service or my service been terminated during probation.. (ii) àÉéèxÉä ÉÊBÉYÉÉÎ{iÉ àÉå nÉÒ MÉ<Ç ¶ÉiÉÉæ BÉEÉä vªÉÉxÉ{ÉÝBÉÇBÉE {Éfà ÉÊãɪÉÉ cé +ÉÉè® àÉé AiÉnÂuÉ®É =xÉBÉEÉ {ÉÉãÉxÉ BÉE®xÉä BÉEÉ BÉSÉxÉ näiÉÉ/näiÉÉÒ cÝÄ * I have read the provisions in the Notice of the examination carefully and hereby undertake to abide by them. I further declare that I will produce OBC Certificate in the prescribed format as stipulated in the Notice of the examination. ¶ÉÖãBÉE ÉÊ]BÉE] BÉEä ÉÊãÉA ºlÉÉxÉ Space for CRF Stamp r 100. I also declare that no criminal case is pending against me. educational qualifications etc.(SCT) dated 8. (vi) * +ÉxªÉ ÉÊ{ÉU½É BÉMÉÇ ºÉä ºÉƤÉÆÉÊvÉiÉ +É£ªÉlÉÉÔ BÉEä ÉÊãÉA àÉé ªÉc £ÉÉÒ PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE àÉé =ºÉ ºÉàÉÝnÉªÉ ºÉä ºÉƤÉÆÉÊvÉiÉ cÝÄ ÉÊVɺÉä BÉEÉÉÌàÉBÉE ABÉÆ |ÉÉʶÉFÉhÉ ÉÊBÉ£ÉÉMÉ BÉEä ÉÊnxÉÉÆBÉE 8. (iv) àÉé ªÉc £ÉÉÒ PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE àÉÖZÉä +ÉÉVÉiÉBÉE BÉEàÉÇSÉÉ®ÉÒ SɪÉxÉ +ÉɪÉÉäMÉ/ºÉÆPÉ ãÉÉäBÉE ºÉäBÉÉ +ÉɪÉÉäMÉ uÉ®É ÉÊBÉEºÉÉÒ £ÉÉÒ {É®ÉÒFÉÉ àÉå ¤Éè~xÉä ºÉä xÉcÉÓ ®ÉäBÉEÉ MɪÉÉ cè iÉlÉÉ àÉÖZÉä ÉÊBÉEºÉÉÒ £ÉÉÒ ÉÊBÉÉÊvÉ xªÉɪÉÉãÉªÉ uÉ®É BÉE£ÉÉÒ £ÉÉÒ nÉäÞÉÉÉÒ xÉcÉÓ {ÉɪÉÉ MɪÉÉ cè * ½ãö ¾ãÖ ¼ããè ÜããñÓã¥ãã ‡ãŠÀ¦ãã/ ‡ãŠÀ¦ããè Öîâ ãä‡ãŠ ½ãì¢ãñ ÔãÀ‡ãŠãÀãè ÔãñÌãã Ôãñ ‡ãŠ¼ããè ¼ããè ºãŒããÃԦ㠶ãÖãé ãä‡ãŠ¾ãã Øã¾ãã Öõ ‚ã©ãÌãã Ö›ã¾ãã ¶ãÖãé Øã¾ãã Öõ ‚ã©ãÌãã ¹ããäÀÌããèàãã ‡ãñŠ ªãõÀã¶ã ½ãñÀãè ÔãñÌãã Ôã½ã㹦㠶ãÖãé ‡ãŠãè ØãƒÃ Öõ ý 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.1993. Further declare that I have never been dismissed or removed from Govt. BÉEä. of Personnel and Training Office Memorandum No. my application will be rejected summarily by the Commission. £É. ºÉÆ. * * For Central Govt. (AºÉºÉÉÒ]ÉÒ) àÉå ÉÊBÉÉÊciÉ +ÉÉnä¶ÉÉå BÉEä +ÉxÉÖºÉÉ® £ÉÉ®iÉ ºÉ®BÉEÉ® uÉ®É ºÉäBÉÉ+ÉÉäÆ àÉå +ÉÉ®FÉhÉ BÉEä |ɪÉÉäVÉxÉ cäiÉÖ ÉÊ{ÉUbÉ BÉMÉÇ àÉÉxÉÉ MɪÉÉ cè * ªÉc £ÉÉÒ PÉÉäÞÉhÉÉ BÉEÉÒ VÉÉiÉÉÒ cè ÉÊBÉE àÉé £ÉÉ®iÉ ºÉ®BÉEÉ®. BÉEÉìãÉàÉ 3 àÉå =ÉÎããÉÉÊJÉiÉ BªÉÉÎBÉDiɪÉÉå/BÉMÉÉæ ( µÉEÉÒàÉÉÒãÉäªÉ®) ºÉä ºÉƤÉÆÉÊvÉiÉ xÉcÉÓ cÝÄ àÉé ªÉc £ÉÉÒ PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE àÉä®ä {ÉÉºÉ {É®ÉÒFÉÉ xÉÉäÉÊ]ºÉ àÉå ÉÊxÉvÉÉÇÉÊ®iÉ |ÉÉ°ó{É àÉå +ÉxªÉ ÉÊ{ÉUbÉ BÉMÉÇ BÉEÉ |ÉàÉÉhÉ {ÉjÉ cè * *For Candidate belonging to OBC.9.36012/22/93-Estt. prescribed for admission to the examination. complete and correct to the best of my knowledge and belief. Civilian Employee and completed 3 years regular service or regular length of service stipulated in the Notice of the examination. 36012/22/93 ºlÉÉ. PÉÉäÞÉhÉÉ /Declaration (i ) àÉéèxÉä <ºÉ £ÉiÉÉÔ BÉEä ÉÊãÉA BÉEÉä<Ç +ÉÉè® +ÉÉBÉänxÉ {ÉjÉ xÉcÉÓ £ÉäVÉÉ cè àÉÖZÉä ªÉc àÉÉãÉÝàÉ cè ÉÊBÉE ªÉÉÊn àÉé <ºÉ ÉÊxɪÉàÉ BÉEÉ =ããÉÆPÉxÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ iÉÉä +ÉɪÉÉäMÉ uÉ®É àÉä®É +ÉÉBÉänxÉ ºÉ®ºÉ®ÉÒ iÉÉè® {É® +ɺBÉÉÒBÉEßiÉ BÉE® ÉÊnªÉÉ VÉÉAMÉÉ * I have not submitted any other application for this examination. YÉÉ.22. ¶ÉèÉÊFÉBÉE ªÉÉäMªÉiÉÉ +ÉÉÉÊn ºÉƤÉÆvÉÉÒ {ÉÉjÉiÉÉ BÉEÉÒ ºÉ£ÉÉÒ ¶ÉiÉÉç BÉEÉä {ÉÝ®É BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ * àÉé ªÉc £ÉÉÒ PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE àÉé <ºÉ {É®ÉÒFÉÉ I further declare that I fulfill all the conditions of eligibility regarding age limits. ¶ÉÖãBÉE ÉÊ]BÉE] ªÉcÉÄ ~ÉÒBÉE fÆMÉ ºÉä ÉÊSÉ{ÉBÉEÉAäÆ iÉlÉÉ bÉBÉEPÉ® ºÉä ®q BÉE®É nå VÉcÉÄ ºÉä BÉc JÉ®ÉÒnÉ MɪÉÉ cè * (º]ä{ÉãÉ xÉ BÉE®å) Paste here firmly CRF Stamp of r 100. 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. D D M M Y Y iÉÉ®ÉÒJÉ/Date: * ªÉÉÊn ãÉÉMÉÝ xÉ cÉä iÉÉä ªÉc ãÉÉ<ÇxÉ BÉEÉ] nå * * Strike off this sentence if not applicable +ÉcºiÉÉFÉÉÊ®iÉ +ÉÉBÉänxÉ {ÉjÉ BÉEÉä ®q BÉE® ÉÊnªÉÉ VÉɪÉäMÉÉ Unsigned application will be rejected (Page 2 of 2) .. £É. (viii) àÉé AiÉn uÉ®É PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE <ºÉ +ÉÉBÉänxÉ {ÉjÉ àÉå ÉÊnA MÉA ºÉ£ÉÉÒ ÉÊBÉBÉ®hÉ àÉä®ÉÒ +ÉÉÊvÉBÉEiÉàÉ VÉÉxÉBÉEÉ®ÉÒ +ÉÉè® ÉÊBɶBÉÉºÉ BÉEä +ÉxÉÖºÉÉ® ºÉiªÉ. =ºÉBÉEä iÉciÉ ={É®ÉäBÉDiÉ BÉEɪÉÉÇãÉªÉ YÉÉ{ÉxÉ ºÉÆ .1993 BÉEä BÉEÉ. (vii) £ÉÝiÉ{ÉÝBÉÇ ºÉèÉÊxÉBÉEÉå BÉEä ÉÊãÉA àÉé PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE àÉé {É®ÉÒFÉÉ ÉÊBÉYÉÉÎ{iÉ BÉEä +ÉxÉÖºÉÉ® £ÉÝiÉ{ÉÝBÉÇ ºÉèÉÊxÉBÉE ºÉƤÉÆÉÊvÉiÉ {ÉÉjÉiÉÉ BÉEÉÒ ºÉ£ÉÉÒ ¶ÉiÉÉç BÉEÉä {ÉÝ®É BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ * For Candidate belonging Ex-Serviceman I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of examination. I am aware that if I contravene this rule. (iii) àÉé ªÉc £ÉÉÒ PÉÉäÞÉhÉÉ BÉE®iÉÉ/BÉE®iÉÉÒ cÝÄ ÉÊBÉE àÉé <ºÉ {É®ÉÒFÉÉ àÉå |ÉBÉä¶É BÉEä ÉÊãÉA ÉÊxÉvÉÉÇÉÊ®iÉ +ÉɪÉÖ ºÉÉÒàÉÉ. ( Do not Staple) ºlÉÉxÉ/Place: ………………………………. {ÉÝhÉÇ ABÉÆ ºÉcÉÒ cè * àÉé ºÉàÉZÉiÉÉ/ºÉàÉZÉiÉÉÒ cÝÄ ÉÊBÉE {É®ÉÒFÉÉ ºÉä {ÉcãÉä ªÉÉ ¤ÉÉn àÉå BÉEÉä<Ç £ÉÉÒ ºÉÝSÉxÉÉ UÖ{ÉÉ<Ç cÖ<Ç/ZÉÝ~ÉÒ ªÉÉ +ɺÉiªÉ {ÉÉ<Ç VÉÉxÉä {É® ªÉÉ +É{ÉÉjÉiÉÉ BÉEÉ {ÉiÉÉ ãÉMÉxÉä {É® àÉä®ÉÒ +É£ªÉÉÌlÉiÉÉ/ÉÊxɪÉÖÉÎBÉDiÉ ÉÊxÉ®ºiÉ BÉEÉÒ VÉÉ ºÉBÉEiÉÉÒ cè * I hereby declare that all statements made in this application are true.