Server 1 Welcome to Odisha Staff Selection Commission http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantI...

ODISHA STAFF SELECTION COMMISSION

Barrack No.1, Unit No.-V, Bhubaneswar-751054 | Tel: 0674- 2393770 | Fax: 0674-2391153
Application Form 160801044764
Applicant Copy (To be retained by the applicant)

01 -
1. Post Code and Name
Assistant Commercial Tax Officer

2. Advertisement No. and Date 2786 - 17-Aug-2016

Choice of district for

3. Bhubaneswar
appearing in the examination
4. Full Name Of the Applicant Mrs. Rasmita Bhanja

5. Father's Name Mr. Dhurba Charan Bhanja

6. Mother's Name Mrs. Basanti Bhanja

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

Mr. Sugyan Kumar Jena

8. Personal Details
a. Nationality b. Religion c. Sex d. Date of Birth. e. Age as on 01-Jan-2016
Indian Hindu Female 01-Jun-1983 Year 32 Month 7

NCC
Reservation Certificate
f. g. h. Physically Challenged (Yes / No) i. Type of Physical disability
Category received, if
any
UR NA No NA

Period of
Service Whether passed
Whether Ex- Date/ Likely Date of Discharge (in case
j. k. rendered (in l. m. minimum Seventh
Serviceman of Ex-Serviceman)
case of Ex- class Exam. in Odia
Serviceman)
NA
No NA Yes

Whether
holder of
ID card no. issued by Director of Sports (in case of
n. Sports o. p. State Level Medal
Sports Person)
Person
Certificate
No NA No

National Level InService (Govt.

q. r. International Level Medal s.
Medal Contractual)
No No No

Total In-Service
t. From u. To v.
Experience
-- -- 0.0

9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address)
Address with
a. Plot- 952/3735 Behera Sahi Nayapalli Bhubaneswar ,Pincode: 751012
Pincode:
b. District : Bhubaneswar c. State : Odisha

d. Telephone : - e. Mobile : 9439191101 f. e-Mail : db.rasmita@gmail.com

10. Permanent Address

Address with
a. Plot- 952/3735 Behera Sahi Nayapalli Bhubaneswar ,Pincode: 751012
Pincode:
b. District : Bhubaneswar c. State : Odisha

11. Educational Qualification

1 of 5 21-10-2017, 01:10
Server 1 Welcome to Odisha Staff Selection Commission http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantI...

10th Standard Roll Number As Mentioned in the Certificate 67TC093

10th Standard Exam Type Annual

Total Marks Calculated For

Examination Stream Board/University YOP Division %Age
Marks/CGPA Division/CGPA
HSC *** BSE, ODISHA 1998 First 750 496 66.13
10+2/
SCIENCE CHSE, ODISHA 2000 First 900 558 62.00
EQUIVALENT
BACHELOR IN UTKAL UNIVERSITY
DEGREE 2003 Second 1800 904 50.22
SCIENCE ODISHA

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

Name of the Post held: - From : - To : -

Whether appointed following due

Whether - -
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
25779DBC24 Date : 20-Sep-2016
Number:
Name of Treasury Bhubaneswar No I Amount 100

14. Application Details

Applicant Id : 160801044764 Password : 3CBF15C60F

NB : Your Online application has been submitted successfully.

ODISHA STAFF SELECTION COMMISSION

Barrack No.1, Unit No.-V, Bhubaneswar-751054 | Tel: 0674-2393770 | Fax: 0674-2391153
Application Form 160801044764
OSSC Copy

01 -
1. Post Code and Name
Assistant Commercial Tax Officer

2. Advertisement No. and Date 2786 - 17-Aug-2016

Choice of district for
3. appearing in the Bhubaneswar
examination
Full Name Of the
4. Mrs. Rasmita Bhanja
Applicant
5. Father's Name Mr. Dhurba Charan Bhanja

6. Mother's Name Mrs. Basanti Bhanja

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

Mr. Sugyan Kumar Jena

8. Personal Details
a. Nationality b. Religion c. Sex d. Date of Birth. e. Age as on 01-Jan-2016
Indian Hindu Female 01-Jun-1983 Year 32 Month 7

NCC
Physically
Reservation Certificate
f. g. h. Challenged i. Type of Physical disability
Category received, if
(Yes / No)
any
UR NA No NA

Period of Date/ Likely

Service Date of
Whether Ex- Whether passed minimum
j. k. rendered (in l. Discharge (in m.
Serviceman Seventh class Exam. in Odia
case of Ex- case of Ex-
Serviceman) Serviceman)

2 of 5 21-10-2017, 01:10
Server 1 Welcome to Odisha Staff Selection Commission http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantI...

NA
No NA Yes

Whether holder
ID card no. issued by Director of Sports (in case of Sports
n. of Sports Person o. p. State Level Medal
Person)
Certificate
No NA No

National Level InService (Govt.

q. r. International Level Medal s.
Medal Contractual)

No No No

Total In-Service
t. From u. To v.
Experience
-- -- 0.0

9. Address for Correspondence (All Communication to the candidate from OSSC is to be made in this address)
Address with
a. Plot- 952/3735 Behera Sahi Nayapalli Bhubaneswar ,Pincode: 751012
Pincode:
b. District : Bhubaneswar c. State : Odisha

d. Telephone : - e. Mobile : 9439191101 f. e-Mail : db.rasmita@gmail.com

10. Permanent Address

Address with
a. Plot- 952/3735 Behera Sahi Nayapalli Bhubaneswar ,Pincode: 751012
Pincode:
b. District : Bhubaneswar c. State : Odisha

11. Educational Qualification

10th Standard Roll Number As Mentioned in the Certificate 67TC093

10th Standard Exam Type Annual

Total Marks Calculated For

Examination Stream Board/University YOP Division %Age
Marks/CGPA Division/CGPA
HSC *** BSE, ODISHA 1998 First 750 496 66.13
10+2/
SCIENCE CHSE, ODISHA 2000 First 900 558 62.00
EQUIVALENT
BACHELOR IN UTKAL UNIVERSITY
DEGREE 2003 Second 1800 904 50.22
SCIENCE ODISHA

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

Name of the Post held: - From : - To : -

Whether appointed following

Whether - -
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
25779DBC24 Date : 20-Sep-2016
Number:
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 :

3 of 5 21-10-2017, 01:10
Server 1 Welcome to Odisha Staff Selection Commission http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantI...

Full Signature of the Applicant (Ink Signed)

4 of 5 21-10-2017, 01:10
Server 1 Welcome to Odisha Staff Selection Commission http://online.odishassc.in/Form/R_PrintOnlineForm_N.aspx?ApplicantI...

Sender By Post

From
Application for the Post of : Assistant
Commercial Tax Officer
Name Mrs. Rasmita Bhanja
Father's Name Mr. Dhurba Charan Bhanja To

Plot No, / Lane Plot- 952/3735 Behera Sahi The Secretary,

Name / Village Nayapalli Bhubaneswar Odisha Staff Selection Commission,
Barrack No.1,
District Name Bhubaneswar
Unit No.-V,
PIN Code 751012
Bhubaneswar-751054 .
Tel: 0674- 2392233
Fax: 0674-2391153

5 of 5 21-10-2017, 01:10