12/26/2015

Server1WelcometoOdishaStaffSelectionCommission

ODISHASTAFFSELECTIONCOMMISSION
BarrackNo.1,UnitNo.V,Bhubaneswar751054|Tel:06742393770|Fax:06742391153

151174051730

ApplicationForm
ApplicantCopy(Toberetainedbytheapplicant)
1. PostCodeandName
2. AdvertisementNo.andDate
3.

Choiceofdistrictforappearing
intheexamination

74

WelfareExtensionOfficer

20Nov2015

5105
Bhubaneswar

4. FullNameOftheApplicant

Mr.DebabrataDash

5. Father'sName

Mr.PurnaChandraDash

6. Mother'sName

Mrs.AvaDash

7. NameofthehusbandincaseofMarriedfemaleapplicant

NA

8.PersonalDetails
a. Nationality
Indian

Hindu

NCC
Reservation
Certificate
g.
Category
received,if
any

f.
UR

NA

WhetherEx
Serviceman

j.

Whether
holderof
n. Sports
Person
Certificate
No

d. DateofBirth.

Male

14Jan1986

e. Ageason01Jan2015
Year 29

h. PhysicallyChallenged(Yes/No)

No

No

NA

o.

NA

Yes

IDcardno.issuedbyDirectorofSports(incaseof
p. StateLevelMedal
SportsPerson)
No

r. InternationalLevelMedal

s.

InService(Govt.
Contractual)
No

No

From

Month

i. TypeofPhysicaldisability

NA

National
LevelMedal

q.

c. Sex

Periodof
Service
Whetherpassed
Date/LikelyDateofDischarge(in
k. rendered(in l.
m. minimumSeventh
caseofExServiceman)
caseofEx
classExam.inOdia
Serviceman)
NA

No

t.

b. Religion

u. To

v.

TotalInService
Experience
0.0

9.AddressforCorrespondence(AllCommunicationtothecandidatefromOSSCistobemadeinthisaddress)
a.

Addresswith
Pincode:

b. District:
d. Telephone:

PlotNoEb503BadagadaBritColonyBhubaneswar,Pincode:751018

c. State:

Khurda
06742312147

e. Mobile:

9078275760

f. eMail:

Odisha

debabrata14dash@gmail.com

10.PermanentAddress
a.

Addresswith
Pincode:

b. District:

PlotNoEb503BadagadaBritColonyBhubaneswar,Pincode:751018
Khurda

c. State:

Odisha

11.EducationalQualification
10thStandardRollNumberAsMentionedintheCertificate

5138183

10thStandardExamType

Annual

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Server1WelcometoOdishaStaffSelectionCommission
Examination

Stream

HSC

Board/University

***

10+2/EQUIVALENT ARTS
DEGREE

YOP Division TotalMarks/CGPA SecuredMarks/CGPA %Age

CBSE,NEWDELHI

2001 Second 500

295

59.00

CHSE,ODISHA

2003 Second 900

489

54.33

1041

57.83

BACHELORINARTS UTKALUNIVERSITYODISHA 2006 Second 1800

12.Workexperiencedetails.(IfinGovt.Service)
NameofthePostheld:

From:

To:

Whether

Whetherappointedfollowingdue
procedure

13.TreasuryChallanDetails(OriginalChallanhastobesubmittedalongwiththehardcopyoftheapplication)(Candidates
belongingtoSC/ST/PWDCategoriesareexemptedfrompayingtheexamfees.)
TreasuryChallan/Reference
Number:

100

Date:

19Dec2015

NameofTreasury

BhubaneswarNoI

Amount

100

CandidateworkingasaSevak&TeacherservingunderST&SCdev.department

No

14.ApplicationDetails
ApplicantId:

151174051730

Password: C1442FCDE1

NB:YourOnlineapplicationhasbeensubmittedsuccessfully.

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12/26/2015

Server1WelcometoOdishaStaffSelectionCommission

ODISHASTAFFSELECTIONCOMMISSION
BarrackNo.1,UnitNo.V,Bhubaneswar751054|Tel:06742393770|Fax:06742391153

151174051730

ApplicationForm
OSSCCopy

1. PostCodeandName
2. AdvertisementNo.andDate
3.

Choiceofdistrictfor
appearingintheexamination

74

WelfareExtensionOfficer

20Nov2015

5105
Bhubaneswar

4. FullNameOftheApplicant

Mr.DebabrataDash

5. Father'sName

Mr.PurnaChandraDash

6. Mother'sName

Mrs.AvaDash

7. NameofthehusbandincaseofMarriedfemaleapplicant

NA

8.PersonalDetails
a. Nationality
Indian

f.

Reservation
Category

UR

j.

WhetherEx
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.

NationalLevel
Medal

No

t. From

TypeofPhysicaldisability

m.

Whetherpassedminimum
SeventhclassExam.inOdia

Yes

Whetherholder
IDcardno.issuedbyDirectorofSports(incaseofSports
n. ofSportsPerson o.
Person)
Certificate
No

Month

29

NA

Periodof
Date/Likely
Service
Dateof
k. rendered(in l. Discharge(in
caseofEx
caseofEx
Serviceman)
Serviceman)
NA

DateofBirth. e. Ageason01Jan2015

NA

p.

StateLevelMedal

s.

InService(Govt.
Contractual)

v.

TotalInService
Experience

No

r. InternationalLevelMedal
No

No

u. To

0.0

9.AddressforCorrespondence(AllCommunicationtothecandidatefromOSSCistobemadeinthisaddress)
a.

Addresswith
Pincode:

b. District:
d. Telephone:

PlotNoEb503BadagadaBritColonyBhubaneswar,Pincode:751018

c. State:

Khurda
06742312147

e. Mobile:

9078275760

f. eMail:

Odisha

debabrata14dash@gmail.com

10.PermanentAddress
a.

Addresswith
Pincode:

b. District:

PlotNoEb503BadagadaBritColonyBhubaneswar,Pincode:751018

c. State:

Khurda

Odisha

11.EducationalQualification
10thStandardRollNumberAsMentionedintheCertificate

5138183

10thStandardExamType

Annual
Total

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

Secured

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12/26/2015

Server1WelcometoOdishaStaffSelectionCommission
Examination

Stream

Board/University

YOP Division

Marks/CGPA

Marks/CGPA

%Age

HSC

***

CBSE,NEWDELHI

2001 Second 500

295

59.00

10+2/
EQUIVALENT

ARTS

CHSE,ODISHA

2003 Second 900

489

54.33

DEGREE

BACHELORIN
ARTS

UTKALUNIVERSITY
ODISHA

2006 Second 1800

1041

57.83

12.Workexperiencedetails.(IfinGovt.Service)
NameofthePostheld:

From:

To:

Whether

Whetherappointedfollowingdue

procedure

CandidateworkingasaSevak&TeacherservingunderST&SCdev.department

No

13.TreasuryChallanDetails(OriginalChallanhastobesubmittedalongwiththehardcopyoftheapplication)
(CandidatesbelongingtoSC/ST/PWDCategoriesareexemptedfrompayingtheexamfees.)
TreasuryChallan/Reference
Number:

100

Date:

19Dec2015

NameofTreasury

BhubaneswarNoI

Amount

100

DECLARATION
I __________________________ Son/ Daughter of Shri _________________________Age___________ Year__________
residentof________________District________________herebydeclarethattheinformationgivenaboveandintheenclosed
documentsistruetothebestofmyknowledgeandbeliefandnothinghasbeenconcealedtherein.Iamwellawareofthefactthat
iftheinformationgivenbymeisprovedfalse/nottrue,Iwillhavetofacethepunishmentasperthelaw.Also,allthebenefits
availedbymeshallbesummarilywithdrawn.

Signatureshouldnotexceedtheboxprovided

Date:

Place:

FullSignatureoftheApplicant(InkSigned)

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Server1WelcometoOdishaStaffSelectionCommission

Sender

By

Post

From

ApplicationforthePostof:Welfare
ExtensionOfficer

Name

Mr.DebabrataDash

Father'sName

Mr.PurnaChandraDash

To

PlotNo,/Lane

PlotNoEb503BadagadaBrit

TheSecretary,

Name/Village

ColonyBhubaneswar

OdishaStaffSelectionCommission,

DistrictName

Khurda

PINCode

751018

BarrackNo.1,
UnitNo.V,
Bhubaneswar751054.
Tel:06742392233
Fax:06742391153

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

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