Affix here CRFS

To be cancelled with Post Office stamp half on CRFS half on Application
STAFF SELECTION COMMISSION
APPLICATION FORM

Combined Graduate Level (Preliminary)
Exam., 2004
Closing Date : 14.11.2003
Date of Exam : 08.02.2004
Paste your recent good quality Passport Size Photograph : Keep 1 identical copy for use in further stages of Recruitment
 

Signature of candidate in box above 
1.  Centre Opted
     (Please see para 14 of the notice)
 
 preferably in black ink/black ball pen
2.  (a) Mode of Payment
      Write :     '1' for CRFS
                      '2' for IPOs
                      '3' for Fee Exemption
 
2.  (b) If fee paid by IPOs then give details as follows
Sl.No.
Serial Number of IPOs
Date of Issue
Amount
Name of issuing Post Office with address
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.  Name of candidate (as recorded in Matriculation or equivalent certificate)
 
4.  Address for communication
 

 

 
Pin
5.  (a) Father's Name
 
5.  (b) Mother's Name
 
6.  Date of Birth
    7.  Sex
8.  Community
     9.  Category
10.  Educational Qualification
D
D
M
M
Y
Y
Y
Y

M

F
GC
SC
ST
OBC
PH
EXS
Graduate
Post Grad.
Appeared in Grad.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

I hereby certify and declare that (a) I have read the provisions in the rules and the Notice of the examination carefully and I hereby undertake to abide by them; (b) All the statements made in the application are true, complete and correct to the best of my knowledge and belief; (c) I fulfill all conditions of eligibility as prescribed in the Notice for admission to the examination; (d) I have not submitted any other application in response to the same notice/ advertisement; (e) I have not been debarred by the Commission and have not been convicted by the court.
In the event of information or part thereof being found false or detected before or after the examination or at any stage and/ or that I am not satisfying the eligibility criteria prescribed in the Notice, my candidature/ appointment is liable to be cancelled/ terminated automatically without any notice to me and actions can be taken against me by the Commission.

Place.............
Date..............
Tick (a) mark whichever is applicable.
Application not signed by the candidate will be rejected.


Signature of the Applicant