2/10/2014

Print Application Form

HARYANA

STAFF SELECTION COMMISSION

Bays No. 67-70, Sector-2, Panchkula-134151 For Office Use Only C ontrol No. : R oll No. : Online A pplication Form Tre asury : Panchkula Adve rtise m e nt No. : 1/2014 Candidate Particulars : R e gistration C andidate Nam e Fathe r's/Husband's Nam e Mothe r's Nam e Date of Birth Age on (As Pe r advt.) Mailing A ddress : Addre ss Contact Details : C ontact Num be r Em ail ID Personal Details : : : : Ye s : : : : : : Indian Male Ye s Urban No a m ole on the le ft e ye brow Passing Marks Year Obtain ENG,HINDI,MATH,S.S,SC I.,SKT. 2007 375 MEC HANIC AL ENGG. 2010 5581 MEC HANIC AL ENGG. 2014 4838 Subjects Physical Handicap PH Sub-C ate gorie s Marital Status C ate gory : : : : : : Total Marks 500 7700 6155 Un-Marrie d Ge ne ral No : H.NO . 622/10,SHEELAPATI MO HALLA NEAR DHAKNIYA MANDIR JIND JIND Haryana-126102 7357234113 singla.shubham 10@gm ail.com Paste he re your late st stam p size , atte ste d photograph : : : : : : 2010579679 SHUBHAM R AM GO PAL KAUSHAL JAIN 10/04/1993 20 Ye ars 10 Months 9 Days Journal No.: .............. C ate gory No. : 1 Date : .............. Post Nam e : C le rk s Am ount : .............. Scrutiny By :

Have you passe d Hindi/Sansk rit upto : Middle /Matric Nationality Ge nde r Are you dom icile of Haryana ? Are a Are you e m ploye d in Govt/Public se ctor unde rtak ing? Ide ntification Mark Qualification Details : Examination Stream

Board/University C .B.S.E H.S.B.T.E K.U.K : no gap

% 75.00 72.48 78.60

Div 1 1 1

Matriculation 10th Inte rm e diate Diplom a ITI/Vocational B.te ch R e ason For Gap (If Any) Experience Details : Non Total Ex pe rie nce : Non

Documents To Be A ttached : Matriculation C e rtificate W ith Mark she e t C opy, Inte rm e diate C e rtificate with Mark she e t copy, Graduation De gre e with all Mark she e tsC opy, C opy of C hallan, All O the r Q ualification De gre e with all Mark she e ts copy, Haryana R e side nt C e rtificate , Driving Lice nce Declaration : I he re by de clare that:1. All state m e nts m ade in this application form are true , com ple te and corre ct to the be st of m y k nowle dge and be lie f. In the e ve nt of any inform ation be ing found false or incorre ct, or ine ligibility be ing de clare d be fore or afte r the inte rvie w/appointm e nt/se le ction, m y candidature m ay be cance lle d and action can be tak e n against m e by the com m ission. 2. I have re ad the provisions in adve rtise m e nt of the C om m ission care fully and I he re by unde rtak e to abide by the m . I fulfill all the conditions of the e ligibility re garding age lim its,e ducational qualifications e tc. pre scribe in the adve rtise m e nt and othe r re le vant rule s and instructions. 3. I have ne ve r be e n convicte d by C rim inal C ourt. Candidate Signature SHUBHAM Name in capital letters Place : Date : 10/02/2014 [ Signature of the Candidate ] Note : Incomplete and unsigned application form shall be rejected.

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