Server 1 Welcome To Odisha Staff Selection Commission 3y5u4n
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12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission
ODISHA STAFF SELECTION COMMISSION Barrack No.1, Unit No.V, Bhubaneswar751054 | Tel: 0674 2393770 | Fax: 06742391153
151174051730
Application Form Applicant Copy (To be retained by the applicant) 1. Post Code and Name 2. ment No. and Date 3.
Choice of district for appearing in the examination
74
Welfare Extension Officer
20Nov2015
5105 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 Indian
Hindu
NCC Reservation Certificate g. Category received, if any
f. UR
NA
Whether Ex Serviceman
j.
Whether holder of n. Sports Person Certificate No
d. Date of Birth.
Male
14Jan1986
e. Age as on 01Jan2015 Year 29
h. Physically Challenged (Yes / No)
No
No
0
NA
o.
NA
Yes
ID card no. issued by Director of Sports (in case of p. State Level Medal Sports Person) No
r. International Level Medal
s.
InService (Govt. Contractual) No
No
From
Month
i. Type of Physical disability
NA
National Level Medal
q.
c. Sex
Period of Service Whether ed Date/ Likely Date of Discharge (in k. rendered (in l. m. minimum Seventh case of ExServiceman) case of Ex class Exam. in Odia Serviceman) NA
No
t.
b. Religion
u. To
v.
Total InService Experience 0.0
9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address) a.
Address with Pincode:
b. District : d. Telephone :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018
c. State :
Khurda 06742312147
e. Mobile :
9078275760
f. eMail :
Odisha
[email protected]
10. Permanent Address a.
Address with Pincode:
b. District :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018 Khurda
c. State :
Odisha
11. Educational Qualification 10th Standard Roll Number As Mentioned in the Certificate
5138183
10th Standard Exam Type
Annual
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
1/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission Examination
Stream
HSC
Board/University
***
10+2/ EQUIVALENT ARTS DEGREE
YOP Division Total Marks/CGPA Secured Marks/CGPA %Age
CBSE, NEW DELHI
2001 Second 500
295
59.00
CHSE, ODISHA
2003 Second 900
489
54.33
1041
57.83
BACHELOR IN ARTS UTKAL UNIVERSITY ODISHA 2006 Second 1800
12. Work experience details.( If in Govt. Service ) Name of the Post held:
From :
To :
Whether
Whether appointed following due procedure
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 / Reference Number:
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
: C1442FCDE1
NB : Your Online application has been submitted successfully.
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
2/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission
ODISHA STAFF SELECTION COMMISSION Barrack No.1, Unit No.V, Bhubaneswar751054 | Tel: 06742393770 | Fax: 06742391153
151174051730
Application Form OSSC Copy
1. Post Code and Name 2. ment No. and Date 3.
Choice of district for appearing in the examination
74
Welfare Extension Officer
20Nov2015
5105 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 Indian
f.
Reservation Category
UR
j.
Whether Ex Serviceman
No
b. Religion Hindu
g.
NCC Certificate received, if any
NA
c. Sex
d.
Male
Physically h. Challenged (Yes / No)
i.
No
NA
Year
14Jan1986
q.
National Level Medal
No
t. From
0
Type of Physical disability
m.
Whether ed minimum Seventh class Exam. in Odia
Yes
Whether holder ID card no. issued by Director of Sports (in case of Sports n. of Sports Person o. Person) Certificate No
Month
29
NA
Period of Date/ Likely Service Date of k. rendered (in l. Discharge (in case of Ex case of Ex Serviceman) Serviceman) NA
Date of Birth. e. Age as on 01Jan2015
NA
p.
State Level Medal
s.
InService (Govt. Contractual)
v.
Total InService Experience
No
r. International Level Medal No
No
u. To
0.0
9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address) a.
Address with Pincode:
b. District : d. Telephone :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018
c. State :
Khurda 06742312147
e. Mobile :
9078275760
f. eMail :
Odisha
[email protected]
10. Permanent Address a.
Address with Pincode:
b. District :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018
c. State :
Khurda
Odisha
11. Educational Qualification 10th Standard Roll Number As Mentioned in the Certificate
5138183
10th Standard Exam Type
Annual Total
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
Secured
3/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission Examination
Stream
Board/University
YOP Division
Marks/CGPA
Marks/CGPA
%Age
HSC
***
CBSE, NEW DELHI
2001 Second 500
295
59.00
10+2/ EQUIVALENT
ARTS
CHSE, ODISHA
2003 Second 900
489
54.33
DEGREE
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 due procedure
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 / Reference Number:
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 enclosed documents is true to the best of my knowledge and belief and nothing has been concealed therein. I am well aware of the fact that if the information given by me is proved false/ not true, I will have to face the punishment as per the law. Also, all the benefits availed by me shall be summarily withdrawn. Signature should not exceed the box provided
Date :
Place :
Full Signature of the Applicant (Ink Signed)
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
4/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission
Sender
By
Post
From
Application for the Post of : Welfare Extension Officer
Name
Mr. Debabrata Dash
Father's Name
Mr. Purna Chandra Dash
To
Plot No, / Lane
Plot No Eb 503 Badagada Brit
The Secretary,
Name / Village
Colony Bhubaneswar
Odisha Staff Selection Commission,
District Name
Khurda
PIN Code
751018
Barrack No.1, Unit No.V, Bhubaneswar751054 . Tel: 0674 2392233 Fax: 06742391153
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
5/5
Server 1 Welcome to Odisha Staff Selection Commission
ODISHA STAFF SELECTION COMMISSION Barrack No.1, Unit No.V, Bhubaneswar751054 | Tel: 0674 2393770 | Fax: 06742391153
151174051730
Application Form Applicant Copy (To be retained by the applicant) 1. Post Code and Name 2. ment No. and Date 3.
Choice of district for appearing in the examination
74
Welfare Extension Officer
20Nov2015
5105 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 Indian
Hindu
NCC Reservation Certificate g. Category received, if any
f. UR
NA
Whether Ex Serviceman
j.
Whether holder of n. Sports Person Certificate No
d. Date of Birth.
Male
14Jan1986
e. Age as on 01Jan2015 Year 29
h. Physically Challenged (Yes / No)
No
No
0
NA
o.
NA
Yes
ID card no. issued by Director of Sports (in case of p. State Level Medal Sports Person) No
r. International Level Medal
s.
InService (Govt. Contractual) No
No
From
Month
i. Type of Physical disability
NA
National Level Medal
q.
c. Sex
Period of Service Whether ed Date/ Likely Date of Discharge (in k. rendered (in l. m. minimum Seventh case of ExServiceman) case of Ex class Exam. in Odia Serviceman) NA
No
t.
b. Religion
u. To
v.
Total InService Experience 0.0
9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address) a.
Address with Pincode:
b. District : d. Telephone :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018
c. State :
Khurda 06742312147
e. Mobile :
9078275760
f. eMail :
Odisha
[email protected]
10. Permanent Address a.
Address with Pincode:
b. District :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018 Khurda
c. State :
Odisha
11. Educational Qualification 10th Standard Roll Number As Mentioned in the Certificate
5138183
10th Standard Exam Type
Annual
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
1/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission Examination
Stream
HSC
Board/University
***
10+2/ EQUIVALENT ARTS DEGREE
YOP Division Total Marks/CGPA Secured Marks/CGPA %Age
CBSE, NEW DELHI
2001 Second 500
295
59.00
CHSE, ODISHA
2003 Second 900
489
54.33
1041
57.83
BACHELOR IN ARTS UTKAL UNIVERSITY ODISHA 2006 Second 1800
12. Work experience details.( If in Govt. Service ) Name of the Post held:
From :
To :
Whether
Whether appointed following due procedure
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 / Reference Number:
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
: C1442FCDE1
NB : Your Online application has been submitted successfully.
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
2/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission
ODISHA STAFF SELECTION COMMISSION Barrack No.1, Unit No.V, Bhubaneswar751054 | Tel: 06742393770 | Fax: 06742391153
151174051730
Application Form OSSC Copy
1. Post Code and Name 2. ment No. and Date 3.
Choice of district for appearing in the examination
74
Welfare Extension Officer
20Nov2015
5105 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 Indian
f.
Reservation Category
UR
j.
Whether Ex Serviceman
No
b. Religion Hindu
g.
NCC Certificate received, if any
NA
c. Sex
d.
Male
Physically h. Challenged (Yes / No)
i.
No
NA
Year
14Jan1986
q.
National Level Medal
No
t. From
0
Type of Physical disability
m.
Whether ed minimum Seventh class Exam. in Odia
Yes
Whether holder ID card no. issued by Director of Sports (in case of Sports n. of Sports Person o. Person) Certificate No
Month
29
NA
Period of Date/ Likely Service Date of k. rendered (in l. Discharge (in case of Ex case of Ex Serviceman) Serviceman) NA
Date of Birth. e. Age as on 01Jan2015
NA
p.
State Level Medal
s.
InService (Govt. Contractual)
v.
Total InService Experience
No
r. International Level Medal No
No
u. To
0.0
9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address) a.
Address with Pincode:
b. District : d. Telephone :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018
c. State :
Khurda 06742312147
e. Mobile :
9078275760
f. eMail :
Odisha
[email protected]
10. Permanent Address a.
Address with Pincode:
b. District :
Plot No Eb 503 Badagada Brit Colony Bhubaneswar ,Pincode: 751018
c. State :
Khurda
Odisha
11. Educational Qualification 10th Standard Roll Number As Mentioned in the Certificate
5138183
10th Standard Exam Type
Annual Total
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
Secured
3/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission Examination
Stream
Board/University
YOP Division
Marks/CGPA
Marks/CGPA
%Age
HSC
***
CBSE, NEW DELHI
2001 Second 500
295
59.00
10+2/ EQUIVALENT
ARTS
CHSE, ODISHA
2003 Second 900
489
54.33
DEGREE
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 due procedure
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 / Reference Number:
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 enclosed documents is true to the best of my knowledge and belief and nothing has been concealed therein. I am well aware of the fact that if the information given by me is proved false/ not true, I will have to face the punishment as per the law. Also, all the benefits availed by me shall be summarily withdrawn. Signature should not exceed the box provided
Date :
Place :
Full Signature of the Applicant (Ink Signed)
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
4/5
12/26/2015
Server 1 Welcome to Odisha Staff Selection Commission
Sender
By
Post
From
Application for the Post of : Welfare Extension Officer
Name
Mr. Debabrata Dash
Father's Name
Mr. Purna Chandra Dash
To
Plot No, / Lane
Plot No Eb 503 Badagada Brit
The Secretary,
Name / Village
Colony Bhubaneswar
Odisha Staff Selection Commission,
District Name
Khurda
PIN Code
751018
Barrack No.1, Unit No.V, Bhubaneswar751054 . Tel: 0674 2392233 Fax: 06742391153
http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=151174051730
5/5
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