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STAFF SELECTION COMMISSION

BLOCK NO. 12, CGO COMPLEX, LODHI ROAD, NEW DELHI


110003

MULTI TASKING STAFF (MTS) EXAMINATION 2019

REGISTRATION NO: 94000245570

APPLICATION IS PROVISIONALLY ACCEPTED


1. NAME AS PER 2. NEW/CHANGED
MATRICULATION 3. FATHER'S NAME 4. MOTHER'S NAME
NAME
CERTIFICATE
ANJEET KUMAR MODI - AVADHESH MODI RENU DEVI
5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2019 7. GENDER
19/06/1996 23.1 MALE
8. CATEGORY 9. ID NUMBER 10. NATIONALITY
OBC 68XXXXXXXX43 CITIZEN OF INDIA
11. MARK OF VISIBLE IDENTIFICATION : MOLE ON CHEEK
12. MATRICULATION (10th CLASS) EXAMINATION 13. MATRICULATION (10th 14. MATRICULATION (10th
BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
JHARKHAND ACADEMIC COUNCIL RANCHI 26010-0069 2011
15. PREFERENCE OF EXAMINATION CENTERS
EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )

4204 - HAZARIBAG 4205 - RANCHI 4206 - DHANBAD


16.1. HAVE YOU ALREADY
JOINED A CIVIL POST BY 16.3. DATE OF DISCHARGE
16.WHETHER EX- 16.2. LENGTH OF SERVICE IN
AVAILING BENEFIT OF FROM ARMED FORCES
SERVICEMAN (ESM)? ARMED FORCES ( IN YEARS )
RESERVATION FOR EX- (DD/MM/YYYY)
SERVICEMAN (ESM) :?
NO - - -
17. WHETHER PERSON WITH DISABILITY 17.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
(PWD) ?
NO -
18.1 WHETHER SUFFERING FROM CEREBRAL PALSY
-
18.2 DO YOU HAVE A PHYSICAL LIMITATION TO WRITE AND SCRIBE IS REQUIRED TO WRITE ON YOUR BEHALF
(CERTIFICATE TO THIS EFFECT FROM THE CHIEF MEDICAL OFFICER/ CIVIL SURGEON & MEDICAL
SUPERINTENDENT OF A GOVERNMENT HEALTH CARE INSTITUTION AS PER NOTICE OF THE EXAMINATION
WOULD BE REQUIRED AT THE TIME OF EXAMINATION)?
-
18.3 WHETHER SCRIBE IS REQUIRED 18.4 WILL YOU MAKE YOUR OWN 18.5 IF SCRIBE IS TO BE
ARRANGEMENT OF SCRIBE? ARRANGED BY SSC, INDICATE
MEDIUM
- - -
19. WHETHER SEEKING AGE RELAXATION? 19.1 IF YES,INDICATE CODE
NO -
20. STATE(S) / U.T. PREFRENCE CODE
K,I,F,J,O,Y,C,G,D,H,2,6,7,5,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X,X
21. EDUCATIONAL QUALIFICATION
B.SC. (HONS.)
22. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?
-
23. DO YOU WANT TO MAKE AVAILABLE YOUR PERSONAL INFORMATION FOR ACCESSING JOB OPPORTUNITY IN
TERMS OF DoP&T'S O.M NO.39020/1/2016-ESTT.(B) DATED 21.06.2016 ?
YES
ADDRESS DETAIL
24. POSTAL ADDRESS 25. PERMANENT ADDRESS
GUMO CHOUDHARY MOHALLA WARD NO 21 JHUMRI GUMO CHOUDHARY MOHALLA WARD NO 21 JHUMRI
TELAIYA KODERMA TELAIYA KODERMA
DISTRICT: KODERMA DISTRICT: KODERMA
STATE: JHARKHAND STATE: JHARKHAND
PIN: 825409 PIN: 825409
MOBILE NO. : 8873188734 EMAIL ID: kumaranjeet501@gmail.com
SIGNATURE

FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE


NOT EXEMPTED 100 CPS0351718 07/05/2019
DECLARATION
1. I HAVE READ THE NOTICE OF THE EXAMINATION AND ACCEPT ALL THE TERMS & CONDITIONS OF
THE NOTICE OF THE EXAMINATION.

2. 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.I AM WILLING TO SERVE ANYWHERE IN INDIA.
PRINT TAKEN ON: 07/05/2019 1:18:36 PM

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