-/ANNEXURE-I

BES Sx +M STAFF SELECTION COMMISSION

BDi xiBE i {F-2015
COMBINED GRADUATE LEVEL EXAMINATION-2015
BE{ {F BE x] nA MA +xn/Mx BBhBE BE Bvx {BBE {f * BD (

) Jx BE A x BE {x BE |M BE *

Please read instructions in the Notice of the Examination/Annexure-II carefully. Use Blue or Black ball pen to write in the box ( (
{F BExp BE x / Name of the Examination Centre

1.

2. BExp BEb / Center Code

3. =nB BE { x (+OV ) ]BEx |h {j nA MA x BE +x +F J * x BE BExc n M BE S ABE BD BE J U n *

Candidates Full Name (in English). Write in Capital Letters exactly as in Matriculation Certificate. Leave a box blank between any two parts of the name.

{i BE x (+OV BE +F J) / Fathers Name (Write in Capital Letters in English)

4.

5. i BE x (+OV BE +F J) / Mothers Name (Write in Capital Letters in English)

6.

7. M / Gender
8. ]i /Nationality
(J 1-j AB 2-{)
(J 1-i AB 2-+x)
(Write 1-Female & 2- Male) (Write 1-Indian & 2 - Others)

Vx BE iJ / Date of Birth

nx / Day

cx /Month

B /Year

10. gh / Category
(J 9-+x,1 +V,2 +VV AB
6-+{B)
(Write 9-General, 1-SC, 2-ST,

10.1 BD +{ i{B xBE c ?

12. BD + U] Sci c?

11.1 n c, BEb

+BEi BE
If yes, indicate code
(Write 4-OH, 5-HH,7-VH )
13 Preference for Posts:
2

11

12

13

21

22 23

4
14

5
15

24 25

16 17
26

27

10

18

19

20

28

29

30

(J 1-c AB 2-xc)
(Write 1-Yes, 2-No)

12.2 (01.08.2015) BE +

Age as on (01.08.2015)

If yes, indicate code

(n +BE BE JiBE BEb +BEi BE)
(Write two digit numeric code)

(J 1-c AB 2-xc) (Write -1-Yes, 2-No)

Whether PH ?

(nx/Day cx/Month B /year)

12.1 n c, BEb +BEi BE

Whether seeking Age relaxation ?

[B /Year]

B +Bv / Length of Service

B {i il/Date of Discharge

(Write Y-Yes, N-No)

6-OBC)

10.3. i{B xBE BE A For Ex-Serviceman

10.2
? If, ExS,
whether seeking reservation?

Whether Ex-serviceman
(J 3-i{B xBE)
(Write 3- Ex-Serviceman)

9. BE / Fee
(J 1-BE BE Mix n 2- U] BE nB BE)
(Write 1-Fee paid & 2- Exemption
claimed)
11. BD +{ BE BBEM

B / Years

14. BD JBE +xBBE Ob-**/BEBE BE {n ci +Bnx BE c c?(J 1-c AB 2-xc)

Are you applying for the Posts of Statistical Investigator Gr.II/ Compiler ?
(Write 1-Yes, 2-No)

BD JBE +xBBE Ob-**/BEBE BE {n ci FBE Mi |{i c?(J 1-c AB 2-xc)

Do you possess EQ for the Posts of Statistical Investigator Grade II/ Compiler?
(Wrire 1-Yes, 2-No)

cx / Months

nx / Days

15. BD +{ +{JBE c?

(J 8-

Whether belong to Minority

Communities
as per Govt. Orders? (Write 8, if yes.
Otherwise leave it blank)

Preferences indicated above are final.

16. n o] vi BBEM/

c, i BD +{BE |{BE BE +BBEi c ? 16.1. n c, v +BEi BE ( +OV BE A 1, cxn BE A 2 J )

If yes, indicate medium, ( Write 1- English, 2-Hindi)

(J 1-c, 2-xc)
If VH/Cerebal Palsy candidate, whether scribe is required ? (Write 1-yes, 2-No)
17. FBE Mi Educational Qualification
BEb +BEi BE Indicate Code

B BEb
Subject Code

+BE BE |ii (%)

Percentage (%) of Marks

v (+OV-1, cxn-2 B +x-3)

Medium ( English-1, Hindi-2, Others-3)

See Annexure-X of the Notice

18. BE +xB BE BBh Details of work Experience / Govt. Service rendered

l BE x
Name of the Organisation(s)

{nx
Designation

19. {i: +{x x ci {j BBc BE { {i +OV BE +F cxn x

BE {x J *
Address: Write your complete Communication Address including your Name in
English Capital Letters or Hindi with Blue or Black Ball Pen.

x Name___________________________________________________
{i Address__________________________________________________
_____________________________________________________________

BE BE BBh
Nature of the Duty(ies)

20. {E]O{E
4 x 5 +BE BE
c c JS M {E]O{E
c ~BE fM S{BE *
(]{ x BE * {E] BE
i{i x BEBA)
Photograph
Paste here firmly your recent photograph
(4 c.m.X 5c.m)
(Do not staple. Do not get the Photograph
attested)

BE BE +Sv /
/From

Period of Service
iBE / To

+xEBE (BEB BE |M ci)

Roll Number ( for Office use
only)

_______________________________________________________________
{x PIN:
< x./ Mobile No. : .........................................................
Email ID:.

21.=nB BE ciF

Signature of the Candidate in the

above Box
Page 1 of 2

22. Ph /Declaration

BE. . BE ]BE] S{BEx

BE n bBEP u q BE
Vx B ]BE] ci lx
Space for cancellation
stamp by post office
after affixing CRF
stamp

23. BE. . BE ]BE] BE A

lx
Space for CRF Stamp
Rs. 100.00 BE BE. .
BE ]BE] c ~BE fM
S{BEA il bBEP
q BE n Vc Bc
Jn M c *
(]{ x BE)

Paste here firmly CRF

Stamp of Rs. 100.00
denomination and get
it cancelled from the
post office where
purchased.
( Do not Staple)

(i ) x < i BE A BE< + +Bnx {j xc V c Z c c BE n < x BE =Px BEi/BEi c i

+M u +Bnx i { +BBEi BE n VAM *
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) x BY{i n M< i BE vx{BBE {f c + Ainu =xBE {x BEx BE BSx ni/ni c *
I have read the provisions in the Notice of the examination carefully and hereby undertake to abide by
them.
(iii) c Ph BEi/BEi c BE < {F |B BE A xvi + , FBE Mi +n v {ji BE
i BE { BEi/BEi c * c Ph BEi/BEi c BE < {F
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) c Ph BEi/BEi c BE Z +ViBE BES Sx +M/P BE B +M u BE {F ~x
xc BE M c il Z BE Bv x u BE n xc { M c * /


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) * + U] Scx B BExp BE BE +xBE BES BE A
c Ph BEi/BEi c BE ABE BExp BE BE ABE +xBE BES c AB xi +v { 3 B BE B
BBE +Bv V BE {F x] xvi c, *
* 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) * +x {U BM vi +l BE A
c Ph BEi/BEi c BE = n vi c V BEBE AB |Fh BM BE nxBE 8.9.1993 BE
BE. Y. . 36012/22/93 l. (A]) Bci +n BE +x i BE u B+ +Fh BE |Vx ci
{Ub BM x M c * c Ph BE Vi c BE i BE, BEBE AB |Fh BM BE Bxx vx V BE
x] =Ji c, =BE ici ={BDi BE Y{x . BE 3 =Ji BBDi/BM ( E) vi
xc c c Ph BEi/BEi c BE { {F x] xvi |{ +x {Ub BM BE |h {j c *
*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 issued from time to time. I further
declare that I will produce OBC Certificate in the prescribed format as stipulated in the Notice of the
examination.
(vii) i{B xBE BE A
Ph BEi/BEi c BE {F BY{i BE +x i{B xBE vi {ji BE i BE { BEi/BEi c *
For Candidate belonging Ex-Serviceman
I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of
examination.
(viii) Ain u Ph BEi/BEi c BE < +Bnx {j nA MA BBh +vBEi VxBE + BB BE +x
i, {h AB c c * Zi/Zi c BE {F {c n BE< Sx U{< c</Z~ +i {< Vx
{ +{ji BE {i Mx { +li/xBDi xi BE V BEi c *
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.
=nB BE ciF
Signature of candidate

lx/Place: ..
D

iJ/Date:

* n M x c i c <x BE] n *
* Strike off this sentence if not applicable

+ciFi +Bnx {j BE q BE n VM
Unsigned application will be rejected
(Page 2 of 2)