ANNEXURE-I

t-t -ttt -tt-t ttttt STAFF SELECTION COMMISSION

t.tt .t .t, t.t` .t .t, tt .t .t tt t.tt .t -t t` tttrt (tt-tt-t t ct ) t t t t` -t t-tt , ze1z
RECRUITMENT FOR THE POST OF CONSTABLE (GENERAL DUTY) IN CAPFs AND RIFLEMAN IN ASSAM RIFLES 2012
i -iii -ii ii i iii` :i -i i` i ~ii ii ;:i ii i` iii` iii ii :iiiiiii -i i i -i. i ii i:i -i i`iii i i` i ii i ii iii -i i ii .iii i i
Please read instruction in the Notice of the Examination/Brochure carefully. Use Blue or Black ball pen to write in the box

1. State / UT of Domicile ||/-|| || || 1.1 State / UT Code ||/-|| || || ii

2. |`-||`|.| -ii ii is ii ii-i;Name of the written Examination Centre 2.1 i s ii ; Center Code

3. --ii ii ii -i i ii-i (~i i ii -i ) -i i` ii ii .i-iii -i-i -i i` i ii-i i ~ii:ii i ~iii -i i` ii ii-i i i` iti i iiii i ii i i ii i :i ii iiii i
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` -iii ii ii-i (~i i ii i i ~iii -i i`ii ) ; Fathers Name (Write in Capital Letters in English)


5. -iiii ii ii-i (~i i ii i i ~iii -i i` ii ) / Mothers Name (Write in Capital Letters in English)




6. i-i ii iii i / Date of Birth

i` i / Day -iti i /Month ii /Year

7. i` ii / Gender
(i` ii ::-ii i z-i i)
(Write 1-Female & 2- Male)
8. i i iii /Nationality
(i` ii :iiii i i z~ii)
(Write 1-Indian & 2 - Others)
9. i i / Fee
( i` ii :i i ii i iiii i z ii iii i` iii)
(Write 1-Fee paid & 2- Exemption claimed)
10. ~i ii / Category

(i` ii ~iii,: ~iii,z ~iiii i s~ii` -ii)
(Write 9-General, 1-SC,2-ST,
6-OBC)

10.1 i ii ~ii-i i i-i i
:ii` ii t ?
Whether Ex-serviceman ?
(i` ii sii-i i :i i` ii)
(Write 3- Ex-Serviceman)
10.2. i i-i i :i i` ii i i` i For Ex-Serviceman
:i ii ~iii` i / Length of Service [ii /Year]
:i ii :i-iii -i i` ii` i /Date of Discharge
i` i/Day -iti i ;Month ii /year)
11. i ii ~iii :ii -ii -i iiti t ?
Whether seeking Age relaxation?
(i` ii :ti , ziti ) (Write -1-Yes, 2-No)
11.1 ii` ti , ii ~i i` ii i
If yes, indicate code
(i ~i ii ii :i ii-ii ii ~i i` ii i )
(Write two digit numeric code)
12. ~iii i .iii -i ii :ii-iii ~ii i-i i` ii` i (01.08.2012) ii ~iii
Age as on normal closing date (01.08.2012)

ii ; Years -iti i / Months i` i / Days
:s i ii ~ii-i ~i-i:i ii t
Whether belong to Minority
Communities?
(i` ii :ti , ziti ) ) (Write -1-Yes, 2- No)
14. i ii ||;|.|| -i iiti t ?
Whether seeking relaxation in
height / chest ?
(i` ii :ti ,ziti ) (Write -1-Yes, 2-No)
14.1 ||` ,| .|| |`|-| ||| | |.||.| ||,.| , ?
If yes, category under which relaxation
sought?
(i` ii :~iiii , z~ii ) (Write -1 for ST, 2
for Others)
15 i ~i ii ii ii ~i i` ii i , ii` ~ii-i
||.||||/ -||-|-||| |~|||`|.| -| /
Write two digit code, If you belong to
Militancy/Naxal affected district.

15.1 i ~i ii ii ii ~i i` ii i , ii` ~ii-i
|`|-| -|
Write two digit code If you belong to
Border district .

16. t.t .t .-i -i ii .iiii` -iiii ;
Preference of post for CAPFs

.iii.1 .iii.2 .iii.3 .iii.4 .iii.s .iii.s
Pref.1 Pref.2 Pref.3 Pref.4 Pref.5 Pref.6
BSF : A
CISF : B
CRPF : C
SSB : D
ITBPF: E
Assam Rifles: F
17. i i` ii ~it ii ii
Educational qualification Code


i` iii ii
Subject Code
~i ii ii .ii` iii (%)
Percentage (%) of Marks



-iii-i (~i i ii :, i` ti z i ~iis,
Medium ( English-1, Hindi-2, Others-3)





18. iii ~iiii ii i` iii Details of work Experience / Govt. Service rendered
:i:ii ii ii-i
Name of the Organisation(s)
-iii-i
Designation
iii ii i` iii
Nature of the Duty(ies)
iii ii ~iii`i / Period of Service
:i /From ii / To


19. t-tt: ~i-ii ii-i :ii` ti -i-i iiti ii -i i -iii ~i i ii i i ~iii -i ii i` ti -i i` ii
Address: Write your complete Address including your Name in English Capital Letters or in Hindi.










Email ID_____________________________________________
19.1 -iiii;i i .; Mobile No. : __________________________________








21. --ii ii i t:iii(i ii i:ii t:ii` ii` -i -i )
Signature of the Candidate in the above Box (Only
in running Hand)




























20. -iii ii-i
+ :i-ii x s :i-ii ~iiii ii
tii ti -i iiii iii -iii ii-i
iti ii . i :i i`i-iiii
(: -ii i i -iii ii
:iiii`-ii i iii)
Photograph
Paste here firmly your recent
photograph
(4 c.m.X 5c.m)
(Do not staple. Do not get the
Photograph attested)

~ii si-ii i (i ii iiii ii .iii i t i ) Roll
Number ( for Office use only)


(1 of 2) (Page 1 of 2)
{j BBc BE {i Postal address
ii-i Name__________________________________________________
__________________________________________________________
__________________________________________________________
___________________________________________________________
i` -ii PIN:
tttt t-tt Permanent / Domicile address
ii-i Name_________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
i` -ii PIN:







ttttt fDeclaration

(i ) -i i ;:i iii i i` i ii ; ~ii ~iii i -i-i iti i ii t -i i it -iii -i t i` i ii` -i ;:i i` ii-i ii i ii iii;iii t ii ~iiii i
ii -i i ~iii i :i:ii ii -i ~i:ii ii i i` ii iiii
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) -i i i` iii -i -i i i; iii ii iii-i i i -i. i` iii t ~ii -i i ii iii -iiii ii ii iii ii; ii t
I have read the provisions in the Notice of the examination carefully and hereby undertake to abide by
them.
(iii) -i it ii ii iii iii;iii t i` i -i ;:i -ii ii -i .ii i i i` i i` iii i` i ~iii :ii -ii, i i` ii ii iii ~iii` :i i ii -ii-iii ii :iii
iii ii -i i iii;iii t
I further declare that I fulfill all the conditions of eligibility regarding age limits, educational qualifications
etc., prescribed for admission to the examination.
(iv) -i it ii ii iii iii;iii t i` i -i i ~iiiii i-i iii iii ~iiii i;:i i ii i :i ii ~iiii i ii i` i:ii ii -ii ii -i i i :i iti
i ii iii t iii -i i i` i:ii ii i` ii` i iiiiii ii iii ii i iii iti -iiii iii t | |, ~|| ||||| |.||/ |.|| , |`| || -||||
-||| -| |~|| ~|| |||-.| -|,| |`||| ||| , |||| ,||| -|,| ||| , |||| ||`|||| | ||-| || -||| -|||.| -|,| || | ,
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) * ~iii :ii -ii -i iiti iii is :iii i ~i:i i` ii i-i iii i i` i
-i it ii iii iii;iii t i` i -i i is :iii ii i ~i:i i` ii i-i iii t i i` iii` -ii ~iiii -i s ii ii :i ii ii :i iiiii
~iii` i i :ii ii -ii ii ii i` :i -i i` iii i` i t , ~iii i -i-i i-ii ii ii ~i i` i-i i` ii` i ii :i:i -i i -i i i ii t
* For Employees of CPOs 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) * ~ii i` -ii ii :i :i i i` ii ~iiii i i` i
-i it ii ii iii iii;iii t i` i -i :i :i-i ii :i :i i i` ii t i` i:i iii` -ii i .ii` iii i` iiii i i` ii i 8.9.1993 i ii. ii.
:i . ssc:z;zz;s :ii. (:i:ii i ) -i i` ii` ti ~ii ii i ~ii :ii iii :iii ii :i ii~ii -i ~iiii i .iii ii t i i` -ii ii -ii ii
iii t it ii ii iii ii iiii t i` i -i iii :iii, iii` -ii i .ii` iii i` iiii i i` ii` ii :i ii iii ii i` i ii i` :i -i i i` ii
t , :ii iti -ii i i iiii ii ii-ii :i . ii i-i s -i i ii` ii ii i iii ;iii ( sii -ii i i) :i :i i i` ii iti t -i it ii ii iii
iii;iii t i` i -i -ii:i -ii ii ii i` :i -i i` iii i` i .ii-i -i ~ii i` -ii ii ii .i-iii -i-i t
*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 i-i i :i i` iii i i` i
-i ii iii iii;iii t i` i -i -ii ii i` iii -i i ~ii:ii i i-i i :i i` ii :ii -ii ii -ii-iii ii :iii iii ii -i i iii;iii t
For Candidate belonging Ex-Serviceman
I declare that I fulfill all the eligibility condition relating to Ex-Serviceman as per notice of examination.
(viii) -i i ii ii iii iii;iii t i` i ;:i ~iii i -i-i -i i` i :iii i` iii -i i ~ii` iii-i iiiiii ~ii i` iii:i i ~ii:ii :ii,
-i i i :iti t -i :i-iiii;:i-iiii t i` i -ii ii :i -iti ii ii -i ii ; ii :i iii -ii; t ; ;i i ii ~i:ii -ii; iii -i ii
~i-ii-iii ii -iii iii -i -i i ~iii` iii;i` ii i i i i` i:i ii ii :iiii t
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.


:iii;Place: ..
D D M M Y Y
iiii;Date:



* ii` iii i ti ii it ii;i ii
* Strike off this sentence if not applicable
--ii ii i t:iii (iii i:ii t:ii` ii` -i -i )
Signature of candidate ( only in running hand)





~it:iiii`i ~iii i -i-i ii i i`ii iiiii
Unsigned application will be rejected

(Page 2 of 2)



zs. i . i. ii i`i i i`i
:iii
Space for CRF Stamp
r 50.00 ii i . i.
ii i`i iti ii . i
:i i`i-iii iii iii :i
ii iti :i it
ii i iii t
(:-ii i i )

Paste here firmly CRF
Stamp of r 50.00
denomination and get
it cancelled from the
post office where
purchased.
( Do not Staple)
i . i. i i i` i i` i-iiii
i ii iii ii i` ii
iii iii i` i t i :iii
Space for cancellation
stamp aby post office
after affixing CRF
stamp