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    This document is an application form for the Junior Engineer (Civil, Electrical, Mechanical and Quantity Surveying & Contracts) Examination 2018 by the Staff Selection Commission. It contains details such as the applicant's personal information including name, date of birth, gender, address, qualification details, exam preferences, and a declaration agreeing to the terms and conditions of the exam notice. The applicant, Pritisoumya Dash, has applied for the Junior Engineer (Civil) post and is seeking age relaxation as a person with disability (OH).

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    This document is an application form for the Junior Engineer (Civil, Electrical, Mechanical and Quantity Surveying & Contracts) Examination 2018 by the Staff Selection Commission. It contains details such as the applicant's personal information including name, date of birth, gender, address, qualification details, exam preferences, and a declaration agreeing to the terms and conditions of the exam notice. The applicant, Pritisoumya Dash, has applied for the Junior Engineer (Civil) post and is seeking age relaxation as a person with disability (OH).

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    This document is an application form for the Junior Engineer (Civil, Electrical, Mechanical and Quantity Surveying & Contracts) Examination 2018 by the Staff Selection Commission. It contains details such as the applicant's personal information including name, date of birth, gender, address, qualification details, exam preferences, and a declaration agreeing to the terms and conditions of the exam notice. The applicant, Pritisoumya Dash, has applied for the Junior Engineer (Civil) post and is seeking age relaxation as a person with disability (OH).

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    41 views2 pages

    DraftPrint 2

    Uploaded by

    pritisoumya dash
    This document is an application form for the Junior Engineer (Civil, Electrical, Mechanical and Quantity Surveying & Contracts) Examination 2018 by the Staff Selection Commission. It contains details such as the applicant's personal information including name, date of birth, gender, address, qualification details, exam preferences, and a declaration agreeing to the terms and conditions of the exam notice. The applicant, Pritisoumya Dash, has applied for the Junior Engineer (Civil) post and is seeking age relaxation as a person with disability (OH).

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    © All Rights Reserved
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    of 2

    STAFF SELECTION COMMISSION

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


    110003
    JUNIOR ENGINEER (CIVIL, ELECTRICAL,
    MECHANICAL AND QUANTITY SURVEYING &
    CONTRACTS) EXAMINATION 2018
    REGISTRATION NO: 84000317928

    APPLICATION IS PROVISIONALLY ACCEPTED


    1. NAME AS PER 2. NEW/CHANGED 3. FATHER'S NAME 4. MOTHER'S NAME
    MATRICULATION NAME
    CERTIFICATE
    PRITISOUMYA DASH - BISWAMBAR DASH BANASRI DASH
    5. DATE OF BIRTH (DD/MM/YYYY) 6. AGE AS ON 01/08/2019 7. GENDER
    17/06/1992 27.1 MALE
    10. MARK OF VISIBLE
    8. CATEGORY 9. NATIONALITY
    IDENTIFICATION
    OPERTION MARK ON RIGHT
    UNRESERVED CITIZEN OF INDIA
    LEG
    11. MATRICULATION (10th CLASS) EXAMINATION 12. MATRICULATION (10th 13. MATRICULATION (10th
    BOARD CLASS) ROLL NO CLASS) YEAR OF PASSING
    BOARD OF SECONDARY EDUCATION, ODISHA 11PD214 2007
    14. PREFERENCE OF EXAMINATION CENTERS
    EXAMINATION CENTER ( FIRST ) EXAMINATION CENTER ( SECOND ) EXAMINATION CENTER ( THIRD )

    BERHAMPORE (ODISHA) ( 4602 ) BHUBANESHWAR ( 4604 ) CUTTACK ( 4605 )


    15.WHETHER EX- 15.1. HAVE YOU ALREADY 15.2. LENGTH OF SERVICE IN 15.3. DATE OF DISCHARGE
    SERVICEMAN (ESM)? JOINED A CIVIL POST BY ARMED FORCES ( IN YEARS ) FROM ARMED FORCES
    AVAILING BENEFIT OF (DD/MM/YYYY)
    RESERVATION FOR EX-
    SERVICEMAN (ESM) :?
    NO - - -
    16. WHETHER PERSON WITH DISABILITY 16.1 IF YES, TYPE OF DISABILITY (OH, HH,VH, OTHERS)
    (PWD) ?
    YES OH
    17. 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)?
    NO
    17.1 WHETHER SCRIBE IS REQUIRED 17.2 WILL YOU MAKE YOUR OWN 17.3 IF SCRIBE IS TO BE
    ARRANGEMENT OF SCRIBE? ARRANGED BY SSC, INDICATE
    MEDIUM
    NO - -
    18. WHETHER SEEKING AGE RELAXATION? 18.1 IF YES,INDICATE CODE
    YES 03-PWD
    19. POST(S) APPLYING FOR 20. MEDIUM FOR PAPER II
    19. POST(S) APPLYING FOR 20. MEDIUM FOR PAPER II
    JUNIOR ENGINEER(CIVIL) ENGLISH
    21. QUALIFICATION DETAILS
    HIGHEST TECHNICAL QUALIFICATION RELEVANT TO SUBJECT
    THE POST OF INTEREST
    DIPLOMA CIVIL ENGINEERING
    22. DO YOU BELONG TO ECONOMICALLY WEAKER SECTIONS (EWS) ?
    NO
    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 ?
    NO
    ADDRESS DETAIL
    24. POSTAL ADDRESS 25. PERMANENT ADDRESS
    HOUSE NO-ER 19 5TH EXT NILACHAL NAGAR HOUSE NO-ER 19 5TH EXT NILACHAL NAGAR

    DISTRICT: GANJAM DISTRICT:GANJAM


    STATE: ODISHA STATE: ODISHA
    PIN : 760010 PIN : 760010
    MOBILE NO: 7381677442 EMAIL: pritisoumyadash91@gmail.com
    SIGNATURE THUMB IMPRESSION

    FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE


    EXEMPTED - - -
    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: 25/02/2019 9:21:49 PM

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