ANNEXURE-I

BES Sx +M STAFF SELECTION COMMISSION

{c (x b]), , BE {n BE A i, 2015

RECRUITMENT FOR THE POST OF CONSTABLE (GENERAL DUTY) IN CAPFs ,NIA, SSF AND RIFLEMAN IN ASSAM RIFLES 2015
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 instruction in the Notice of the Examination/Brochure carefully. Use Blue or Black ball pen to write in the box
1.
2.

1.1 Domicile State / UT Code / BEb

State / UT of Domicile /
2.1

{F BExp BE x

2.2

/Mode of Exam

(J 1-, 2- )

Center Code

Name of the written Examination Centre

(write 1-online and 2-offline)

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 part 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

7. M / Gender

nx / Day

(J 1-j AB 2-{)
(Write 1-Female & 2- Male)

cx /Month

B /Year

10. gh / Category

10.1 BD +{ i{B

xBE c ?
(J 9-+x,1 +V,2 +VV AB 6-+{B) Whether Ex-serviceman ?
(Write 9-General, 1-SC,2-ST,
6-OBC)

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

10.2.

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

i{B xBE BE A For Ex-Serviceman

B +Bv / Length of Service

If yes, indicate code

(n +BE BE JiBE BEb +BEi BE )
(Write two digit numeric code)

B / Years

14.1 ?
If yes, category under which relaxation
sought?
(J 1-+VV , 2-+x ) (Write -1 for ST, 2
for Others)

11. BD + U] Sci c?

Whether seeking Age relaxation?

[B /Year]

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

B {i il /Date of Discharge
nx/Day cx/Month B /year)

12. 01.01.2015 BE +
Age as on (01.01.2015)

11.1 n c, BEb +BEi BE

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

Whether belong to Minority

Communities?

14. BD / U] Sci c?
Whether seeking relaxation in
height / chest ?

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

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

13 BD +{ +{JBE c ?

cx / Months

nx / Days

15 n +BE BE BEb +BEi BE, n +{

/ /

15.1 n +BE BE BEb +BEi BE, n +{

16. BE.{.. {n BE
|lBEi /

Write two digit code, If you belong to

Militancy/Naxal affected district.

Write two digit code If you belong to

Border district .

Preference of post for CAPFs &

Assam Rifles
1

6
7
8
Put X if not opted.

17. FBE +ci BEb

Educational qualification Code

B BEb
Subject Code

+BE BE |ii (%)

Percentage (%) of Marks

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

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

18. {i: +{x x ci {j BBc BE { {i +OV BE +F cxn J *

Address: Write your complete Address including your Name in English Capital Letters or in Hindi.

{j BBc BE {i Postal address

x Name__________________________________________________
__________________________________________________________
___________________________________________________________
{x PIN:

19.
{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)

+xEBE (BEB BE |M ci)

Roll Number ( for Office use only)

l {i Permanent / Domicile address

x Name _________________________________________________
_________________________________________________________
____________________________________________________
{x PIN:
Email ID
_____________________________________
19.1 < x./ Mobile No. : __________________________________

=nB BE ciF)
Signature of the Candidate in the above Box

(1 of 2)

BSF : A
CISF : B
CRPF : C
SSB : D
ITBPF: E
Assam Rifles: F
NIA: G
SSF: H

Ph /Declaration
BE. . BE ]BE] S{BEx
BE n bBEP u q BE
Vx B ]BE] ci lx
Space for cancellation
stamp aby post office
after affixing CRF
stamp

20. BE. . BE ]BE] BE A

lx
Space for CRF Stamp
Rs 50.00 BE BE. .
BE ]BE] c ~BE fM
S{BEA il bBEP
q BE n Vc Bc
Jn M c *
(]{ x BE)

Paste here firmly CRF

Stamp of Rs. 50.00
denomination and get
it cancelled from the
post office where
purchased.
( Do not Staple)

(i ) x < i BE A BE< + +Bnx {j xc V c Z c c BE n < x BE =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 ... 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, +Bnx {j V BEx BE +i il = {B {h BE c *
* For Employees of CAPFs and Assam Rifles 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 on or before date of closing of submitting application
form given in the Notice.
(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 a 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 Indi DOPT OMs mentioned in the Notice. I further declare that I am in possession of
OBC Certificate in the prescribed format given 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 xvi {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
Signature of candidate

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