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http://164.100.129.99/chsl/pdfprint/verifyprint.jsp 1/2 Application Registration No: 600******** for the Combined Higher Secondary Level Examination 2016 Your Application is Completed

1.& 2. Name of Computer Based written Examination Center and Code : CR Gorakhpur(3007) CR Allahabad(3003)

CR Lucknow(3010)

3.Candidate Name : AJARUDDIN ANSARI

4.Father's Name : RAZZAK ANSARI

5.Mother's Name : ROSHANTARA NESHA

6.Date of Birth (dd/mm/yyyy) : 12/10/1995

7.Gender : Male

8. Nationality : Indian

9.Fee Exemption claimed : Fee Paid

10.Category : OBC

10.1.Whether Ex Serviceman? : No

10.2. For Ex Serviceman Length of Service(in years) : 10.2. Date of discharge (dd/mm/yyyy) :

10.3. Whether eligible for Ex Serviceman Reservation? : 11. Whether PH (PWD) : No

11.1. If yes, indicate code :

11.2. Whether suffering from cerebral palsy? :

11.2. If VH/Cerebal Palsy candidate, whether scribe is required ? 11.3. if yes indicate medium :

12. Whether seeking Age relaxation? : No

12. If yes, indicate code :

12.1. Age(as on 01.01.2017) : 21.2

13. Preference for posts : PLECD

14. Indicate medium for Typing Test : English

14.1. Do you possess knowledge of Typing Test ? : Yes 15. Aadhar Card Number (If available): 870*********-**.Mark of Visible Identification : A CUT OF LEFT HEAND SIDE 17. Whether you belong to Religious Minority Community ? : No 18. Educational Qualification : B.Sc.

19. Do you want to make available your personal Information for the accessing job opportunity in terms of DoP & T's O.M.No. 39020/1/2016 Estt.

(B) dated 21.06.2016 ? :

No

20.Postal Address :

VILL AMWA POST SOHANRIA DIST DEORIA PIN

274408

Village/City : AMWA

District : DEORIA

State : Uttar Pradesh

Pincode : 274408

21.Permanent Address :

VILL AMAWA POST SOHANRIA DIST DEORIA

PIN 274408

State : Uttar Pradesh

Pincode : 274408

STD Code :

Phone Number :

Mobile Number : 983-***-****

Email ID : ac2vws@r.postjobfree.com

23.Photo 24.Signature

02/11/2016 164.100.129.99/chsl/pdfprint/verifyprint.jsp http://164.100.129.99/chsl/pdfprint/verifyprint.jsp 2/2 Payment Details :

Transaction id : IK000LGSV7

Transaction Date(yyyy mm dd) : 2016 10 21

Payment Mode :

Amount :

Declaration

I hereby declare that all the 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 and after examination, my candidature/appointment is liable to be cancelled. Place:

Date (yyyy mm dd):2016 10 21

Signature of Candidate

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