IIARYANA PUSLCNCRVICEOMMISSION Repiatrntlon I)

(6582.36547855857

I'ot Nw
Ilwya(vNervem (GKeeutlve Srueb) her Alled Servlees -202.5

lole Detal

Applemt Nne KAL CHIAUIIAN Mublle Nos 9729HGO S6A

(endeIMale

Ikall KAPENTIIAKU UMAILCOM

Date of IWirth 14.05-1994

(ategoyi GNRAL/UN USIRVI) Nutlonallty: CIIIZUN OV INDIA

Iather'N Nume SIIVKUMAR CHAUDAN Mother' Nume MI!!NA D!VI

Ilave y0u ever beendebarrvd by UPSCAIPSC%ther Stute PSCN or uny other

(Goverument Deprtoent No

Iluve youever been convleted by Crlalnal Court: No

Are you 4n employee of Govt. of 1lurymat No

Sub Category Detall

Applleable Sub Calegory: Nonc

Pernanent Address

Address: lhousc no 00, Srcct no 00

State: IHuryana D0strlet: Punchkula Tehsil: Barwala

'Town/Vllage: Mauli Pin Code: 134||8

Correspondenco Address

Address: Iousc o 00, Srcct no (00

Stule: Haryana Distrlet: Panchkula Tehsll: Barwala

TowwVilluge: Mauli Pln Code: 134|18

Date : (4/2 /23

Candidate signature
Date of lPrlnting:14/12/2023
 Reglstrution ID
HARYANA PUBLIC SERVICE COMMISSION 658236547855857

Bank Account Details

Name of the Account Holder

KupilChuuban

Bank Account No
20457205330

Name of the Bank

Sbi

IFSC Code
SBINO007604

Are you donnicile of Haryana State? Yes

Payment Detail
Bank Refrence Number: 85308069867

Order ID: 67939065823042

Payment amount: P 1000.00

Payment date: 14-12-2023

Qualifying Examínation

Name of the
Qualification Board/University/ Passing
Year
Roll Marks Total
Institution Number Obtained Marks Percentage
Matric
Central Board of Secondary
2010 2142612 275 500
Education (CBSE) 55.00
10+2
Central Board of Secondary
2012 2645086 354 500
Education (CBSE) 70.80
Commerce
(BACHELOR OF Kurukshetra University, Haryana 2016 2895908 1942 3600 53.94
COMMERCE)

Have you worked or are you presently working on adhoc/contract/ work-charged / daily wages basis in any
Departnment/Board/Corporation of Haryana Government to claim age relaxation? No

Employecs of Haryana Government or HighCourt or any Court Subordinatethercto,having at least 4 years No

service in a substantive or officiating (excludingad-hoc)capacity on or before 01.01.2023.

Optional Subject Details

Optlonal Subject For The Main Exam: Indiun History (14)

Date : 422o23
Place :
Mouly
Candidatbd signature
Date of Printing : 14II2/2023
 HARYANA PUBLICSERVICE COMMISSION Registration ID
658236547855857
Post Prefrence Details

Post Prefrence Details

Prefrence I Haryana CivilServices (Executive Branch)

Prefrence 2 'A'Class Naib Tehsildar

Prefrence 3 Block Development & Panchayat Officer

Prefrence 4 Excise & Taxation Officer

Prefrence 5
Assistant Registrar Cooperative Societies

Prefrence 6 District Food &Supplies Officer

Prefrence 7
District Food & Supplies Controller

Prefrence 8 Assistant Excise & Taxation Oficer

Prefrence 9
Traffic Manager

Prefrence 10
Assistant Employment Officer

Uploaded Documents

S.N.
Document Name

Document for Matric

2
Document for 10+2

3
Document for Qualifying Examination

Declaration
Ihave filled up my particulars and Iverify that I have read the same and
found the same to be corect as per the original documents and have not concealed
anything, and
thereafter submitted the same. If at any stage, any particular in the application form is found
incorrec/false as per available data, then
my candidature shall be liable to be
rejecced/cancelled without giving me any opportunity of hearing, at any stage i.e., prior to/after my recruitment/appointment.

Date :
Place :
I4}2)2023
Mouli Candidate signature
Date of Printing : 14/12/2023
3