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8/6/2015 Server 1 Welcome to Odisha Staff Selection Commission

http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantId=150875000651 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)

150875000651

1. Post Code and Name75

Inspector Of Cooperative Societies

2. Advertisement No. and Date 3733 03Aug2015

3. Choice of district for appearingin the examination Bhubaneswar

4. Full Name Of the Applicant Mr. Bijaya Kumar Mallik

5. Father's Name Mr. Bhaskar Mallik

6. Mother's Name Mrs. Santilata Mallik

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 04Jul1990 Year 24 Month 6

f. ReservationCategory g.

NCCCertificatereceived, ifany

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

SC 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: AtRautara Pur PoBt Pur PsAgarapada ,Pincode: 756115

b. District : Bhadrak c. State : Odisha

d. Telephone : e. Mobile : 9090143287 f. eMail : [email protected]

10. Permanent Address



11. Educational Qualification

10th Standard Roll Number As Mentioned in the Certificate 59SCO75

10th Standard Exam Type Annual



Examination Stream Board/University YOP Division Total Marks/CGPA Secured Marks/CGPA %AgeHSC *** BSE, ODISHA 2009 Third 600 255 42.50DIPLOMA ARTS CHSE, ODISHA 2011 Second 600 334 55.66DEGREE BACHELOR IN ARTS BJB COLLEGE 2014 Second 1800 810 45.00Computer application PGDCA ECIL 2013 First 400 350 87.50

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: NA Date : NA

Name of Treasury NA Amount 0

14. Application Details

Applicant Id : 150875000651 Password : 17E7C8B125

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

150875000651

1. Post Code and Name75

Inspector Of Cooperative Societies

2. Advertisement No. and Date 3733 03Aug2015

3. Choice of district forappearing in the examination Bhubaneswar

4. Full Name Of the Applicant Mr. Bijaya Kumar Mallik

5. Father's Name Mr. Bhaskar Mallik

6. Mother's Name Mrs. Santilata Mallik

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 04Jul1990 Year 24 Month 6

f. ReservationCategory g.NCCCertificatereceived, ifany

h.PhysicallyChallenged(Yes / No)

i. Type of Physical disability

SC 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 : e. Mobile : 9090143287 f. eMail : [email protected]

10. Permanent Address



11. Educational Qualification

10th Standard Roll Number As Mentioned in the Certificate 59SCO75

10th Standard Exam Type Annual

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



HSC *** BSE, ODISHA 2009 Third 600 255 42.50DIPLOMA ARTS CHSE, ODISHA 2011 Second 600 334 55.66DEGREE BACHELOR IN ARTS BJB COLLEGE 2014 Second 1800 810 45.00Computer application PGDCA ECIL 2013 First 400 350 87.50

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) (Candidates belonging to SC/ST/PWD Categories are exempted from paying the exam fees.)Treasury Challan / ReferenceNumber: NA Date : NA

Name of Treasury NA Amount 0

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. Bijaya Kumar Mallik

Father's Name Mr. Bhaskar Mallik

Plot No, / LaneName / Village

AtRautara Pur PoBt Pur PsAgarapada

District Name Bhadrak

PIN Code 756115

By Post

Application for the Post of : Inspector OfCooperative Societies

To

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

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