ONLY ONLINE APPLICATION WILL BE ACCEPTED.

FORM IS INDICATIVE

-/ANNEXURE-I

BES Sx +M

STAFF SELECTION COMMISSION

JUNIOR ENGINEER(CIVIL/MECHANICAL/ELECTRICAL AND QUANTITY SURVEYING AND
CONTRACT) EXAMINATION 2014
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 ( (
1.

{F BExp BE x / Name of the Examination Centre

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.

4.

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

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

6.

Vx BE iJ / Date of Birth

nx / Day

cx /Month

7. M / Gender
(J 1-j AB 2-{)
(Write 1-Female & 2- Male)

B /Year

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

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

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

B+Bv / Length of Service

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

10

11

12

12.2 (01.01.2014) BE +

Age as on (01.01.2014)

If yes, indicate code

Whether seeking Age relaxation ?

(n +BE BE JiBE BEb +BEi BE)

(Write two digit numeric code)

B / Years

cx / Months

nx / Days

14. BD +{ +{JBE c?

13

(J 8- c )
Whether belong to Minority Communities
as per Govt. Orders? (Write 8, if yes.
Otherwise leave it blank)

Please see para 14(A) of notice of the examination

15 Subject for General Engineering,Paper-I&Paper-II(Write A for Civil & Structural B for

Electrical & C for Mechanical)
17. FBE Mi Educational Qualification
BEb +BEi BE Indicate Code

Whether PH ?
(J 1-c AB 2-xc)
(Wrire 1-Yes, 2-No)

(nx/Day cx/Month B /year)

12.1 n c, BEb +BEi BE

(J 4-+.B., 5-g.B.)
(Write 4-OH, 5-HH,7-VH )
13 Preference for Posts:
1

11. BD +{ BE BBEM c

[B /Year]

B {i il/Date of Discharge

12. BD + U] Sci c?

+BEi BE
If yes, indicate code

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

10.1 BD +{ i{B xBE c ?

6-OBC)

11.1 n c, BEb

8. ]i /Nationality
(J 1-i AB 2-+x)
(Write 1-Indian & 2 - Others)

B BEb
Subject Code

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)

+BE BE |ii (%)

Percentage (%) of Marks

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

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

See Annexure-VIII 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

21. +xEBE (BEB BE |M ci)

Roll Number ( for Office use only)

________________________________________________________
22.=nB BE ciF (BEB P] ci{ )

{x PIN:

Signature of the Candidate in the

above Box (Only in running Hand)

< x./ Mobile No. : .........................................................

Email ID:.

Page 1 of 2

23. Ph /Declaration
(i ) x < i BE A BE< + +Bnx {j xc V c Z c c BE n < x B E =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 *
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational
qualifications etc., prescribed for admission to the examination.
(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 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{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 (BEB P] ci{ )
Signature of candidate ( only in running hand)

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)