Application Registration No : 60000126109 for Combined Graduate Level Examination-2016

1.& 2. Examination Center and Code :

NR-Delhi(2201)

3. Candidate Name :

KSHITIJ TRIPATHI

4. Father's Name :

SUSHIL KUMAR TRIPATHI

5. Mother's Name :

KANCHAN BALA TRIPATHI

6. Date of Birth(dd/mm/yyyy):

05/05/1995

7. Gender :

Male

8. Nationality :

Indian

9. Fee Exemption claimed :

Fee Paid

10. Category :

General

10.1. Whether Ex-Serviceman? :

No

10.2. If, ExS, Whether seeking reservation? :

10.3. For Ex-Serviceman-Length of Service(in years) :
10.3. Date of discharge :
11. Whether PH :

No

11.1. If yes, indicate code :

12. Whether seeking Age relaxation :

No

12.1. If yes, indicate code :

12.2. Age(as on 01.01.2016) :

21.3

13. Preference for posts :

ABCDEFIJKLMNOPQRSTUVWXYZ@$#%GH

14. Are you applying for the posts of Statistical Investigator Gr.II/ Compiler ? : Yes
14. Do you possess EQ for the posts of Statistical Investigator Grade II/
Compiler? :

Yes

14. Are you applying for the posts of AAO ? :

Yes

14. Do you possess EQ for the posts of AAO ? :

Yes

15. Whether you belong to Religious Minority Communities as per Govt.

Orders ? :

No

16. If VH/ Cerebal Palsy candidate, whether scribe is required ? :

No

16.1. If yes, indicate medium :

17. Aadhar Card Number :

18. Qualification Details (Start from Graduation) :

Educational Qualification

Subject

Percentage(%)of Marks

Medium

B.TECH

Electronics & Communication Engineering

65.0

English

19. Details of Work Experience/Govt. Service rendered :

Name of the Organisation(s)

Designation

Nature of Duty(ies)

Period Of Service
From(mm/yyyy)

Period Of Service
To(mm/yyyy)

Nil

Nil

Nil

Nil

Nil

Contact Details Form :

20. Postal Address :

C-90 CANAL ROAD NEAR RACHIT HOSPITAL DAUDPUR GORAKHPUR

State :

Uttar Pradesh

Pincode :

273001

21. Permanent Address :

C-90 CANAL ROAD NEAR RACHIT HOSPITAL DAUDPUR GORAKHPUR

State :

Uttar Pradesh

Pincode :

273001

STD Code :
Phone Number :
Mobile Number :

9990073356

Email ID :

reachkshitijtripathi@gmail.com

Payment Details Form :

Transaction id :

021785823

Transaction Date(yyyy-mm-dd) :

2016-03-09

Payment Mode :

offline

Amount :

100

PHOTOGRAPH AND SIGNATURE :

SCANNED PHOTOGRAPH OF THE CANDIDATE:

SCANNED SIGNATURE OF THE CANDIDATE

DECLARATION:
I hereby declare that all the 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 false or incorrect at any stage or not satisfying the eligibility criteria according to the requirements of the relative
advertisement, my candidature/appointment is liable to be cancelled/terminated. I am willing to serve anywhere in India.
Place:
Date(yyyy-mm-dd) : 2016-03-09
Signature of Candidate