CCC / CCC+ EXAMINATION REGISTRATION FORM

FOR AFTER TRAINING EXAM FOR EMPLOYEES OF STATE GOVERNMENT

NOTE: ALL INFORMATION SHOULD BE FILL IN ENGLISH CAPITAL LETTERS ONLY 1 2 3 4 NAME OF SECRETARIAT NAME OF DEPARTMENT NAME OF INSTITUTE / OFFICE OFFICE ADDRESS : : : : PHONE NUMBER 5 NAME AND DESIGNATION OF HEAD OF INSTITUTE / OFFICE CONTACT NUMBERS AND E-MAIL ADDRESS NAME OF EMPLYEE ( STARTING WITH SURNAME ) DESIGNATION GPF ACCOUNT NO DATE OF BIRTH AGE DATE OF JOINING 11.1 IN GOVT . SERVICE 11.2 DEPARTMENT 12 13 14 15 16 17 18 19 DATE OF RETIREMENT PERMANENT RESIDENTIAL ADDRESS SEX MARITAL STATUS CAST WHETHER PHYSICALLY HANDICAPPES ? WHETHER EX- SERVICEMAN WHETHER LIKELY TO BE PRAMOTED / HIGHER SCALE WITH IN MONTHES : ( M) : : : : : : : : : : : : : : : : PHONE NUMBER 0- MALE / 1 - FEMALE 0 - UNMARRIDE / 1 - MARRIED 2 - DIVORCED / 3 - WIDOW 0 GENERAL / 1- SC / 2-ST/ 3- OBC YES / NO YES / NO 3 / 6 / 9 / 12 NOT APPLICABLE ( O) Passport Size Photograph

6 7 8 9 10 11

SIGNATURE OF EMPLOYEE

SIGNATURE OF HEAD OF EXAM CENTRE

SIGNATURE OF HEAD OF EMPLOYEES OFFICE

CUT FROM HERE.....................................................

ADMIT CARD
NAME OF EXAM CENTRE DATE OF EXAMINATION NAME OF EMPLOYEE SEAT NUMBER TRIAL NUMBER : : : : : 1 ( One ) / 2 ( Two) / 3 (Three) Passport Size Photograph

SIGNATURE OF HEAD OF EXAM CENTRE

SIGNATURE OF HEAD OF EMPLOYEES OFFICE

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