Regist rat ion ID :

Haryana Staff Selection

Commission 110739

1. Applicant 's Name: RAKHI

2. Fat her's Name: SUBHASH CHANDER

3. Mot her's Name: SHARMILA DEVI

4. Gender: FEMALE

5. Dat e of Birt h: 26/08/2001

6. Marit al St at us: UNMARRIED

7. Nat ionalit y: INDIAN

8. Visible Indent it y Mark on body: NO

9. If any FIR is lodged/Pending NO

against t he applicant ?:
10. Address & Cont act Det ails:
HOUSE NO.- 30/ ST REET NO.- 3/ LAND
MARK- GAIRAT PUR BASS/ PINCODE-
122101, GAIRAT PURBAS, GURGAON BL,
GURUGRAM, HARYANA, 122101

11. Mobile No : 8700007101

12. Email Id : rakhivanshi99@gmail.com

Reservat ion Det ails

13. Cat egory: SC

14. Benchmark Disabilit y : NO

15. EWS : NO

16. Ex-Serviceman : NO

17. Int erest ed Job Cat egory : GROUP C & D

18. Eligible Sport s Person (ESP): NO

19. Are you domicile of Haryana St at e: YES

20. Is DESM (Ex-Servicemen Dependent )?: NA

21. Did you passed/st udying Hindi/Sanskrit in class 10t h or YES

above?:
22. Payment Det ail: FEE NOT PAID YET

23. Would you be availing t he benefit of reservat ion policy of NA

Goverment of Haryana in recruit ment t o Group C and Group D
post s?:

Qualifying Examinat ion Det ails

Education Board / University Result Roll No. Marksheet Grading Mark T otal Percentage
T ype No. System Obtained Marks

Class10th Haryana Board of Pass 2017105441 034898 Non 367 500 73.4
School Education CGPA

Class12th Haryana Board of Pass 3019260294 024779 Non 444 500 88.8
School Education CGPA
 Socio Economic Crit eria

1. Any person from among t he applicant 's fat her, mot her, NO
spouse, brot her and son is/ was or has been a regular
employee in any depart ment / Board/ Corporat ion/ Company/
St at ut ory Body/ Commission/ Aut horit y of Government of
Haryana or any ot her st at e Government or Government of
India:

2. Is Applicant a Widow? : NO

3. Is fat her of candidat e is deceased? : NO

4. If t he applicant belongs t o such a denot ified t ribe(Vimukt NO

Jat is and Tapriwas Jat is) or Nomadic t ribe of Haryana which
is net her a Scheduled Cast e nor a Backward Class. :
5. Age relaxat ion due t o experience: NO

Experience Det ails

Declarat ion by Candidat e

1. I have not sent any ot her applicat ion for t his recruit ment . I know if I violat e t his rule. My applicat ion will
be cancelled by t he St aff Select ion Commission.

2. I have carefully read all t he condit ions given in t he release and hereby I am eligible for t his post and
abide by t hem I promise to.

3. I also declare t hat I fulfils all t he condit ion relat ed age limit s, educat ional qualificat ions and finds
which are prescribed for t his recruit ment .

4. For Ex-Servicemen, I announce t hat I fulfils all t he condit ions of Ex-Serviceman relat ed eligibilit y as per
advert isement .

5. I also declare t hat t ill dat e I have not been prevent ed from appearing in any examinat ion / experient ial
course by any agency / select ion commit t ee of t he St at e of Haryana and have not been convict ed by
any legal court .

6. For t he candidat es belonging to t he Ot her Backward Classes, I declare t hat I belong to t he communit y
which has been considered as a backward class for t he purpose of reservat ion in services by t he St at e
Government , as per t he St at e Government orders. It is also announced t hat t he St at e Government , by
t he various amendment s ment ioned in t he not ice are not relat ed to t he ment ioned individuals /
cat egories. I also declare t hat I have a cert ificat e of OBC.

7. I also declare t hat I have applied only in one reserved cat egory prescribed by t he Government of
Haryana.

8. I hereby declare t hat all t he det ails given in t his applicat ion form are t rue, complet e and correct as per
my maximum informat ion and belief. I underst and / underst and t hat my candidat ure / appoint ment can
be cancelled if any informat ion is found to be hidden / false or unt rue or if ineligibilit y is det ect ed.

Place : gurugram

Dat e : 04/10/2021
Candidat e Signat ure : ------------