Government of India

Staff Selection Commission

Print Form
STAFF SELECTION COMMISSION
BLOCK NO. 12, CGO COMPLEX, LODHI ROAD, NEW DELHI

110003
Combined Graduate Level Examination
REGISTRATION NO: 10012987236

Application Completed(Contents Not Verified)

1. CANDIDATE'S NAME (AS PER THE

2. NEW/ CHANGED NAME 3. GENDER 4. CATEGORY
MATRICULATION CERTIFICATE)
CHETAN KUMAR REGAR - Male SC

7. DATE OF BIRTH (DD/MM/YYYY)

5. FATHER'S NAME 6. MOTHER'S NAME
(AS PER THE MATRICULATION CERTIFICATE)
KAILASH CHANDRA REGAR MAGNI DEVI 20/01/2004

8. AGE AS ON 01/08/2025 9. NATIONALITY 10. VISIBLE IDENTIFICATION MARK

21 Years 6 Months 13 Days Citizen of India MOLE ON STOMACH

11. WHETHER A PERSON WITH BENCHMARK DISABILITY (PwBD) ? 11.1. IFYES, TYPE OF DISABILITY (OH, HH, VH, OTHERS)
No -
12. MATRICULATION (10th CLASS) EXAMINATION BOARD 13. MATRICULATION (10th CLASS) YEAR OF PASSING 14. MATRICULATION (10th CLASS) ROLL NO.

Board of Secondary Education, Rajasthan 2020 1342696

ADDRESS DETAILS

15.1 CORRESPONDENCE ADDRESS 16.1 PERMANENTADDRESS

KARDATEH KARDA DIST BHILWARA RAJASTHAN KARDATEH KARDA DIST BHILWARA RAJASTHAN

15.2. STATE: Rajasthan 16.2. STATE: Rajasthan

15.3. DISTRICT: Bhilwara 16.3. DISTRICT: Bhilwara
15.4. PIN: 311804 16.4. PIN: 311804

17. EMAIL [email protected] 18. MOBILE NUMBER 9549053287

19. HIGHEST EDUCATIONAL QUALIFICATION

Graduation
20. DETAILS OF QUALIFYING EDUCATIONAL QUALIFICATION

Graduation
20.1. EQ STATUS 20.2. PASSING YEAR 20.3. STATE/ UT of BOARD/ UNIVERSITY

Passed 2025 Rajasthan

20.4. NAME OF BOARD/ UNIVERSITY

MAHARISHI DAYANAND SARASWATI UNIVERSITY

20.5. ROLL NUMBER 20.6. PERCENTAGE 20.7. CGPA

308245 53.1

21. WHETHER YOU ARE AN EX-SERVICEMAN (ESM) OR SERVING IN THE ARMED FORCES? 21.1 DATE OF JOINING THE ARMED FORCES (DD/MM/YYYY)
No -

21.2. DATE OF DISCHARGE FROM ARMED FORCES (DD/MM/YYYY)? 21.3. LENGTH OF SERVICE IN ARMED FORCES

- -

21.4. HAVE YOU ALREADY JOINED A CIVIL POST BYAVAILING BENEFIT OF RESERVATION FOR EX-
21.5. DATE OF JOINING TO CIVIL POST (DD/MM/YYYY)
SERVICEMAN (ESM) ?
No -

22. WHETHER SEEKING AGE RELAXATION ? 22.1. IFYES, AGE RELAXATION CODE

No

23. DO YOU WANT TO MAKE YOUR PERSONAL INFORMATION AVAILABLE FOR ACCESSING JOB OPPORTUNITIES IN TERMS OF DOP&T'S OM NO.39020/1/2016-ESTT.(P) DATED 21/06/2016?

Yes
24. PREFERENCE OF EXAMINATION CENTER

24.1. EXAMINATION CENTER (FIRST PREFERENCE ) 24.2. EXAMINATION CENTER (SECOND PREFERENCE ) 24.3. EXAMINATION CENTER (THIRD PREFERENCE )
NR-Ajmer (2401) NR-Udaipur (2409) NR-Jaipur (2405)

25.1. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF BLINDNESS (VH)?

No

25.2. ARE YOU A PERSON WITH BENCHMARK DISABILITIES (40% OR MORE) IN THE CATEGORY OF BOTH ARMS AFFECTED (BA) OR CEREBRAL PALSY (CP)?

No
 25.3. DO YOU HAVE PHYSICAL LIMITATION TO WRITE AS PER PARA 7.2 OR 7.3 OF THE NOTICE?
(CERTIFICATE TO THIS EFFECT FROM COMPETENTATHORITYAS PER FORMATATANNEXURE-1/ANNEXURE-1ATO THE NOTICE OF EXAMINATION, WOULD BE REQUIRED AT THE TIME OF EXAMINATION)?

No

25.4. WHETHER SCRIBE IS REQUIRED?

No

25.5. WILLYOU MAKE YOUR ARRANGEMENT OF SCRIBE?

No

25.6. IF SCRIBE IS TO BE ARRANGED BY SSC, THEN INDICATE MEDIUM?

26.1 ARE YOU ALSO APPLYING FOR THE POST OF JUNIOR STATISTICAL OFFICER (MOSPI)?

No

26.2 DO YOU POSSESS EQ FOR THE POST OF JUNIOR STATISTICAL OFFICER (MOSPI): STATISTICAL OFFICER (MOSPI)?

No
27.1 ARE YOU ALSO APPLYING FOR THE POST OF STATISTICAL INVESTIGATOR GRADE II (RGI): STATISTICAL OFFICER (MOSPI)?

No

27.2 DO YOU POSSESS EQ FOR THE POST OF STATISTICAL INVESTIGATOR GRADE II (RGI)?

No

FEE PAYMENT AMOUNT TRANSACTION NO TRANSACTION DATE

EXEMPTED - - -

DECLARATION

1. I HAVE READ THE NOTICE OF EXAMINATION AND ACCEPTALL THE TERMS & CONDITIONS MENTIONED THEREIN.

2. I HEREBY DECLARE THATALL 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.

3. I AGREE TO AUTHORIZE SSC TO USE MYAADHAAR DATA FOR VERIFICATION PURPOSE.

PRINT TAKEN ON: 13-06-2025 7:51 PM

NUMBER OF ATTEMPT(s): 1

(Signature)

IP ADDRESS:

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