server 1 welcome to odisha staff selection commission

12/26/2015 Server 1 Welcome to Odisha Staff Selection Commission

http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730 1/5

ODISHA STAFF SELECTION COMMISSIONBarrack No.1, Unit No.V, Bhubaneswar751054 | Tel: 0674 2393770 | Fax: 06742391153

Application Form Applicant Copy (To be retained by the applicant)

151174051730

1. Post Code and Name74

Welfare Extension Officer

2. Advertisement No. and Date 5105 20Nov2015

3. Choice of district for appearingin the examination Bhubaneswar

4. Full Name Of the Applicant Mr. Debabrata Dash

5. Father's Name Mr. Purna Chandra Dash

6. Mother's Name Mrs. Ava Dash

7. Name of the husband in case of Married female applicant

NA

8. Personal Details

a. Nationality b. Religion c. Sex d. Date of Birth. e. Age as on 01Jan2015

Indian Hindu Male 14Jan1986 Year 29 Month 0

f. ReservationCategory g.

NCCCertificatereceived, ifany

h. Physically Challenged (Yes / No) i. Type of Physical disability

UR NA No NA

j. Whether ExServiceman k.

Period ofServicerendered (incase of ExServiceman)

l. Date/ Likely Date of Discharge (incase of ExServiceman) m.Whether passedminimum Seventhclass Exam. in Odia

No NA NA Yes

n.

Whetherholder ofSportsPersonCertificate

o. ID card no. issued by Director of Sports (in case ofSports Person) p. State Level Medal

No NA No

q. NationalLevel Medal r. International Level Medal s. InService (Govt.

Contractual)

No No No

t. From u. To v. Total InServiceExperience

0.0

9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address)

a. Address withPincode: Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018

b. District : Khurda c. State : Odisha

d. Telephone : 06742312147 e. Mobile : 9078275760 f. eMail : [email protected]

10. Permanent Address



11. Educational Qualification

10th Standard Roll Number As Mentioned in the Certificate 5138183

10th Standard Exam Type Annual



Examination Stream Board/University YOP Division Total Marks/CGPA Secured Marks/CGPA %AgeHSC *** CBSE, NEW DELHI 2001 Second 500 295 59.0010+2/ EQUIVALENT ARTS CHSE, ODISHA 2003 Second 900 489 54.33DEGREE BACHELOR IN ARTS UTKAL UNIVERSITY ODISHA 2006 Second 1800 1041 57.83

12. Work experience details.( If in Govt. Service )

Name of the Post held: From : To :

Whether Whether appointed following dueprocedure

13. Treasury Challan Details (Original Challan has to be submitted along with the hard copy of the application) (Candidatesbelonging to SC/ST/PWD Categories are exempted from paying the exam fees.)Treasury Challan / ReferenceNumber: 100 Date : 19Dec2015

Name of Treasury Bhubaneswar No I Amount 100

Candidate working as a Sevak & Teacher serving under ST & SC dev. department No

14. Application Details

Applicant Id : 151174051730 Password : C1442FCDE1

NB : Your Online application has been submitted successfully.



ODISHA STAFF SELECTION COMMISSIONBarrack No.1, Unit No.V, Bhubaneswar751054 | Tel: 06742393770 | Fax: 06742391153

Application Form OSSC Copy

151174051730

1. Post Code and Name74

Welfare Extension Officer

2. Advertisement No. and Date 5105 20Nov2015

3. Choice of district forappearing in the examination Bhubaneswar

4. Full Name Of the Applicant Mr. Debabrata Dash

5. Father's Name Mr. Purna Chandra Dash

6. Mother's Name Mrs. Ava Dash

7. Name of the husband in case of Married female applicant

NA

8. Personal Details

a. Nationality b. Religion c. Sex d. Date of Birth. e. Age as on 01Jan2015

Indian Hindu Male 14Jan1986 Year 29 Month 0

f. ReservationCategory g.

NCCCertificatereceived, ifany

h.PhysicallyChallenged(Yes / No)

i. Type of Physical disability

UR NA No NA

j. Whether ExServiceman k.

Period ofServicerendered (incase of ExServiceman)

l.

Date/ LikelyDate ofDischarge (incase of ExServiceman)

m. Whether passed minimumSeventh class Exam. in Odia

No NA NA Yes

n.Whether holderof Sports PersonCertificate

o. ID card no. issued by Director of Sports (in case of SportsPerson) p. State Level Medal

No NA No

q. National LevelMedal r. International Level Medal s. InService (Govt.Contractual)

No No No

t. From u. To v. Total InServiceExperience

0.0

9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address)



d. Telephone : 06742312147 e. Mobile : 9078275760 f. eMail : [email protected]

10. Permanent Address



11. Educational Qualification

10th Standard Roll Number As Mentioned in the Certificate 5138183

10th Standard Exam Type Annual

Total Secured



Examination Stream Board/University YOP Division Marks/CGPA Marks/CGPA %Age

HSC *** CBSE, NEW DELHI 2001 Second 500 295 59.0010+2/EQUIVALENT ARTS CHSE, ODISHA 2003 Second 900 489 54.33

DEGREE BACHELOR INARTS

UTKAL UNIVERSITYODISHA 2006 Second 1800 1041 57.83

12. Work experience details.( If in Govt. Service )

Name of the Post held: From : To :

Whether Whether appointed following dueprocedure

Candidate working as a Sevak & Teacher serving under ST & SC dev. department No

13. Treasury Challan Details (Original Challan has to be submitted along with the hard copy of the application) (Candidates belonging to SC/ST/PWD Categories are exempted from paying the exam fees.)Treasury Challan / ReferenceNumber: 100 Date : 19Dec2015

Name of Treasury Bhubaneswar No I Amount 100

DECLARATION

I __________________________ Son/ Daughter of Shri _________________________Age___________ Year__________resident of ________________ District ________________ hereby declare that the information given above and in the encloseddocuments is true to the best of my knowledge and belief and nothing has been concealed therein. I am well aware of the fact thatif the information given by me is proved false/ not true, I will have to face the punishment as per the law. Also, all the benefitsavailed by me shall be summarily withdrawn.

Date : Place :

Signature should not exceed the box provided

Full Signature of the Applicant (Ink Signed)



Sender

From

Name Mr. Debabrata Dash

Father's Name Mr. Purna Chandra Dash

Plot No, / LaneName / Village

Plot No Eb 503 Badagada BritColony Bhubaneswar

District Name Khurda

PIN Code 751018

By Post

Application for the Post of : WelfareExtension Officer

To

The Secretary,Odisha Staff Selection Commission,Barrack No.1,Unit No.V, Bhubaneswar751054 .Tel: 0674 2392233Fax: 06742391153

server 1 welcome to odisha staff selection commission

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